Provider Demographics
NPI:1528704996
Name:GRIM, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GRIM
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 1:669 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:MS
Mailing Address - Zip Code:39119-5639
Mailing Address - Country:US
Mailing Address - Phone:479-208-3513
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty