Provider Demographics
NPI:1023789039
Name:GRIMES- ACOSTA, KELLY (LGMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRIMES- ACOSTA
Suffix:
Gender:F
Credentials:LGMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 CRAIGTOWN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1801
Mailing Address - Country:US
Mailing Address - Phone:410-910-9693
Mailing Address - Fax:
Practice Address - Street 1:20 CRAIGTOWN RD STE 103
Practice Address - Street 2:
Practice Address - City:PORT DEPOSIT
Practice Address - State:MD
Practice Address - Zip Code:21904-1801
Practice Address - Country:US
Practice Address - Phone:410-910-9693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health