Provider Demographics
NPI:1548854219
Name:GRIMES, IRISA MARIE (OTD)
Entity type:Individual
Prefix:
First Name:IRISA
Middle Name:MARIE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 CENTENNIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7909
Mailing Address - Country:US
Mailing Address - Phone:541-255-2681
Mailing Address - Fax:
Practice Address - Street 1:2519 21ST AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1738
Practice Address - Country:US
Practice Address - Phone:908-868-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR446714225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist