1124552765 NPI number — DR. MARIKA PERS FAYTELL GRIMM PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124552765 NPI number — DR. MARIKA PERS FAYTELL GRIMM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAYTELL GRIMM
Provider First Name:
MARIKA
Provider Middle Name:
PERS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAYTELL
Provider Other First Name:
MARIKA
Provider Other Middle Name:
PERS
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1124552765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 NASHUA ST UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02145-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-374-5129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 GREENFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH DEERFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01373-9753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-475-0086
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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