MEDICARE: MARYAM MARDANBIGI GRIMWOOD LPC

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	101YM0800X	Mental Health Counselor	P1804043	AR
2	101YM0800X	Mental Health Counselor	A1109095	AR
3	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1437190360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAM MARDANBIGI GRIMWOOD LPC

Provider Business Mailing Address
First Line	:	2314 E POLK DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4991
Country	:	US
Telephone Number	:	479-601-1004
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 W CENTER ST
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-6073
Country	:	US
Telephone Number	:	479-316-7770
Fax Number	:

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

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	02/06/2019

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