Provider Demographics
NPI:1497046981
Name:GRIMM, VESSELA
Entity type:Individual
Prefix:
First Name:VESSELA
Middle Name:
Last Name:GRIMM
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 1:24699 FAIR OAKS LN
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-0353
Mailing Address - Country:US
Mailing Address - Phone:310-985-3406
Mailing Address - Fax:
Practice Address - Street 1:5221 ZELZAH AVE APT 104
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2114
Practice Address - Country:US
Practice Address - Phone:310-985-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CAMFC53481106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist