Provider Demographics
NPI:1154820553
Name:AMANDA GRODEWALD-ADLER, PSY.D., PLLC
Entity Type:Organization
Organization Name:AMANDA GRODEWALD-ADLER, PSY.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:GRODEWALD-ADLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:631-209-5343
Mailing Address - Street 1:1919 MIDDLE COUNTRY RD STE 308
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3501
Mailing Address - Country:US
Mailing Address - Phone:631-209-5343
Mailing Address - Fax:
Practice Address - Street 1:1919 MIDDLE COUNTRY RD STE 308
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-209-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019388261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)