Provider Demographics
NPI:1730607862
Name:GRIMES, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GRIMES
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 1:409 CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2961
Mailing Address - Country:US
Mailing Address - Phone:985-210-6710
Mailing Address - Fax:504-558-4937
Practice Address - Street 1:409 CORTEZ ST
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2961
Practice Address - Country:US
Practice Address - Phone:985-210-6710
Practice Address - Fax:504-558-4937
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health