Provider Demographics
NPI:1225174766
Name:GRODSKI, ALEXIS MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:MARIE
Last Name:GRODSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:NEW SUFFOLK
Mailing Address - State:NY
Mailing Address - Zip Code:11956-0152
Mailing Address - Country:US
Mailing Address - Phone:516-375-4777
Mailing Address - Fax:631-734-2412
Practice Address - Street 1:300 TUTHILL ROAD
Practice Address - Street 2:
Practice Address - City:NEW SUFFOLK
Practice Address - State:NY
Practice Address - Zip Code:11956-0152
Practice Address - Country:US
Practice Address - Phone:516-375-4777
Practice Address - Fax:631-734-2412
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015130-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist