Provider Demographics
NPI:1124552765
Name:FAYTELL GRIMM, MARIKA PERS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIKA
Middle Name:PERS
Last Name:FAYTELL GRIMM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARIKA
Other - Middle Name:PERS
Other - Last Name:FAYTELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:9 NASHUA ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-2515
Mailing Address - Country:US
Mailing Address - Phone:413-374-5129
Mailing Address - Fax:
Practice Address - Street 1:235 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-9753
Practice Address - Country:US
Practice Address - Phone:413-475-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program