Provider Demographics
NPI:1194941997
Name:GRIMM, MARK STEPHEN (MSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S PEORIA ST
Mailing Address - Street 2:100
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-5476
Mailing Address - Country:US
Mailing Address - Phone:303-306-4321
Mailing Address - Fax:303-369-3022
Practice Address - Street 1:2400 S PEORIA ST
Practice Address - Street 2:100
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5476
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:303-369-3022
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9850171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO300474Medicare PIN