Provider Demographics
NPI:1255375127
Name:GRIMWOOD, KATHY A (MA)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:GRIMWOOD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-334-3370
Mailing Address - Fax:541-334-3372
Practice Address - Street 1:330 S GARDEN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8176
Practice Address - Country:US
Practice Address - Phone:541-334-3370
Practice Address - Fax:541-334-3372
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21346231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119060Medicaid
P56866Medicare UPIN
OR119060Medicaid