Basic Information
| Provider Information | |||||||||
| NPI: | 1154822161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMES | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 CARROLLTON AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657149179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178808484 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2018 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39003215A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.