Provider Demographics
NPI:1194123299
Name:GRIMES, TERESA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 FOX VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2510
Mailing Address - Country:US
Mailing Address - Phone:407-463-5139
Mailing Address - Fax:
Practice Address - Street 1:806 FOX VALLEY DR
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2510
Practice Address - Country:US
Practice Address - Phone:407-463-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 13258235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA 13258OtherFL LICENSE