Provider Demographics
NPI:1538828850
Name:DEJESUS-GRIMM, AERIEL (PT)
Entity type:Individual
Prefix:
First Name:AERIEL
Middle Name:
Last Name:DEJESUS-GRIMM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AERIEL
Other - Middle Name:
Other - Last Name:DEJESUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3676
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47735-3676
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:
Practice Address - Street 1:6215 E FLORIDA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2877
Practice Address - Country:US
Practice Address - Phone:812-401-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014250A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist