Provider Demographics
NPI:1073058707
Name:GRINDELL, STEPHANIE (MA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GRINDELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DAHLIA LN
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5405
Mailing Address - Country:US
Mailing Address - Phone:631-484-4018
Mailing Address - Fax:
Practice Address - Street 1:55 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2133
Practice Address - Country:US
Practice Address - Phone:631-579-3503
Practice Address - Fax:631-446-1136
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP02689174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist