MEDICARE: DARA NATAKA ADESIMBO GRIMES M.ED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171M00000X	Case Manager/Care Coordinator
2	101YM0800X	Mental Health Counselor
3	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1689377673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARA NATAKA ADESIMBO GRIMES M.ED

Provider Business Mailing Address
First Line	:	6359 PATTERSON RD
Second Line	:
City	:	SNOW CAMP
State	:	NC
Zip	:	27349-9015
Country	:	US
Telephone Number	:	336-814-1731
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 N FAYETTEVILLE ST
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-3203
Country	:	US
Telephone Number	:	336-814-1731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	06/06/2023

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