Provider Demographics
NPI:1306435607
Name:FIFER-GRIMES, REBECCA JANE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:FIFER-GRIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 BOBCAT TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9454
Mailing Address - Country:US
Mailing Address - Phone:317-294-6353
Mailing Address - Fax:
Practice Address - Street 1:3209 W SMITH VALLEY RD STE 143
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-8514
Practice Address - Country:US
Practice Address - Phone:833-914-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99102270A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical