Provider Demographics
NPI:1932805744
Name:FAZLOLLAHI, SIMA
Entity type:Individual
Prefix:
First Name:SIMA
Middle Name:
Last Name:FAZLOLLAHI
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 1:37 WATER ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3058
Mailing Address - Country:US
Mailing Address - Phone:857-917-9000
Mailing Address - Fax:
Practice Address - Street 1:37 WATER ST STE 1
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3044
Practice Address - Country:US
Practice Address - Phone:781-851-2648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health