Provider Demographics
NPI:1437190360
Name:GRIMWOOD, MARYAM MARDANBIGI (LPC)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:MARDANBIGI
Last Name:GRIMWOOD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 E POLK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4991
Mailing Address - Country:US
Mailing Address - Phone:479-601-1004
Mailing Address - Fax:
Practice Address - Street 1:112 W CENTER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6073
Practice Address - Country:US
Practice Address - Phone:479-316-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1804043101YM0800X
ARA1109095101YM0800X
170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No170300000XOther Service ProvidersGenetic Counselor, MS