Provider Demographics
NPI:1821008947
Name:FAJNZYLBER, MARCEL (EDD)
Entity Type:Individual
Prefix:MR
First Name:MARCEL
Middle Name:
Last Name:FAJNZYLBER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4274
Mailing Address - Country:US
Mailing Address - Phone:617-734-5243
Mailing Address - Fax:617-879-0325
Practice Address - Street 1:1141 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5528
Practice Address - Country:US
Practice Address - Phone:617-277-9400
Practice Address - Fax:617-879-0325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA03502103T00000X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0517607Medicaid
MA0517607Medicaid