Provider Demographics
NPI:1972910610
Name:GRIMES, LILLIE MICHELLE (PHD)
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:MICHELLE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 E VERBONCOEUR DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-4550
Mailing Address - Country:US
Mailing Address - Phone:907-715-8175
Mailing Address - Fax:
Practice Address - Street 1:642 S ALASKA ST STE 220
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6378
Practice Address - Country:US
Practice Address - Phone:907-331-0220
Practice Address - Fax:855-702-2532
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK142607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program