Provider Demographics
NPI:1093350605
Name:GRANDE, MARILYN DUFFY (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:DUFFY
Last Name:GRANDE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 E LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MONTAUK
Mailing Address - State:NY
Mailing Address - Zip Code:11954-5218
Mailing Address - Country:US
Mailing Address - Phone:516-650-9693
Mailing Address - Fax:
Practice Address - Street 1:790 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4516
Practice Address - Country:US
Practice Address - Phone:631-427-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059277-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker