Healthcare Provider Details

I. General information

NPI: 1821008947
Provider Name (Legal Business Name): MARCEL FAJNZYLBER ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 BEACON ST
BROOKLINE MA
02446-5528
US

IV. Provider business mailing address

1871 BEACON ST
BROOKLINE MA
02445-4274
US

V. Phone/Fax

Practice location:
  • Phone: 617-277-9400
  • Fax: 617-879-0325
Mailing address:
  • Phone: 617-734-5243
  • Fax: 617-879-0325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03502
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number03502
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number03502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: