Provider Demographics
NPI:1134711625
Name:GRIMES, MACKENZIE ELISE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELISE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 MABEL DR APT 9104
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-3764
Mailing Address - Country:US
Mailing Address - Phone:615-504-8175
Mailing Address - Fax:
Practice Address - Street 1:1909 MALLORY LN STE 200
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2842
Practice Address - Country:US
Practice Address - Phone:615-771-1100
Practice Address - Fax:615-771-1109
Is Sole Proprietor?:No
Enumeration Date:2021-02-07
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN289082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry