Provider Demographics
NPI:1871930974
Name:GRIMES, JUSTIN (MS, CFY-SLP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GRIMES
Suffix:
Gender:M
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S FERDON BLVD STE A1
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5287
Mailing Address - Country:US
Mailing Address - Phone:850-994-3456
Mailing Address - Fax:
Practice Address - Street 1:4100 S FERDON BLVD STE A1
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist