MEDICARE: MALLORY THERESE GRIMM M.ED, BCBA, COBA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	COBA.01005.	OH

General Provider Information

NPI Number	:	1962143503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY THERESE GRIMM M.ED, BCBA, COBA

Provider Business Mailing Address
First Line	:	6005 LANDERHAVEN DR STE B1
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-4042
Country	:	US
Telephone Number	:	216-343-1198
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 LANDERHAVEN DR STE B1
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-4042
Country	:	US
Telephone Number	:	216-343-1198
Fax Number	:

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

Provider Enumeration Date	:	04/06/2022
Last Update Date	:	04/06/2022

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