Provider Demographics
NPI:1043038060
Name:GRIMM, MICHELE LYNN
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:GRIMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BARR ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3502
Mailing Address - Country:US
Mailing Address - Phone:260-710-1275
Mailing Address - Fax:
Practice Address - Street 1:1200 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3504
Practice Address - Country:US
Practice Address - Phone:260-467-1150
Practice Address - Fax:260-467-1188
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1079963103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool