Basic Information
| Provider Information | |||||||||
| NPI: | 1093165391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIM | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | COLUNGA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43145 SUGAR ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935366700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092238826 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 45111 FERN AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619491206 | ||||||||
| FaxNumber: | 6619405452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 107146 | 01 | CA | LINCENSE MARRIAGE FAMILY THERAPIS | OTHER | IMF80914 | 01 | CA | REGISTRATION NUMBER FOR MARRIAGE FAMILY THERAPIST INTERN | OTHER |