Healthcare Provider Details

I. General information

NPI: 1306435607
Provider Name (Legal Business Name): REBECCA JANE FIFER-GRIMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 W SMITH VALLEY RD STE 143
GREENWOOD IN
46142-8514
US

IV. Provider business mailing address

7311 BOBCAT TRAIL DR
INDIANAPOLIS IN
46237-9454
US

V. Phone/Fax

Practice location:
  • Phone: 833-914-4688
  • Fax:
Mailing address:
  • Phone: 317-294-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99102270A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: