MEDICARE: DR. MARIKA PERS FAYTELL GRIMM PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1124552765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIKA PERS FAYTELL GRIMM PH.D.

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

Provider Business Practice Location Address
First Line	:	235 GREENFIELD RD
Second Line	:
City	:	SOUTH DEERFIELD
State	:	MA
Zip	:	01373-9753
Country	:	US
Telephone Number	:	413-475-0086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2017
Last Update Date	:	04/21/2019

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