Basic Information
| Provider Information | |||||||||
| NPI: | 1528267622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIM | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MRC CRC LICDC PCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434020029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193525387 | ||||||||
| FaxNumber: | 4193525439 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W GYPSY LANE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434024572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193525387 | ||||||||
| FaxNumber: | 4193525439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 00051709 | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 021255 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E0007946 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.