Provider Demographics
NPI:1013219120
Name:GROBSTEIN, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GROBSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MERRIEWOLD LN N
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1916
Mailing Address - Country:US
Mailing Address - Phone:845-837-9085
Mailing Address - Fax:
Practice Address - Street 1:22 MERRIEWOLD LN N
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-1916
Practice Address - Country:US
Practice Address - Phone:845-837-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist