Provider Demographics
NPI:1386253102
Name:GRIMSLEY, DAMIEN C (LMT)
Entity type:Individual
Prefix:
First Name:DAMIEN
Middle Name:C
Last Name:GRIMSLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WINDSOR ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-2850
Mailing Address - Country:US
Mailing Address - Phone:860-394-9118
Mailing Address - Fax:
Practice Address - Street 1:123 WINDSOR ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-2850
Practice Address - Country:US
Practice Address - Phone:860-394-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT29.010384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty