Provider Demographics
NPI:1699117507
Name:GRIMMER, TARA (MS ED/SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRIMMER
Suffix:
Gender:F
Credentials:MS ED/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 BRYANT STRATTON WAY
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6013
Mailing Address - Country:US
Mailing Address - Phone:716-631-5777
Mailing Address - Fax:716-631-9432
Practice Address - Street 1:4444 BRYANT STRATTON WAY
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6013
Practice Address - Country:US
Practice Address - Phone:716-631-5777
Practice Address - Fax:716-631-9432
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist