Provider Demographics
NPI:1376274787
Name:GROTH, TAYLOR (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:
Last Name:GROTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WASHINGTON AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2787
Mailing Address - Country:US
Mailing Address - Phone:631-681-4059
Mailing Address - Fax:
Practice Address - Street 1:994 W JERICHO TPKE STE 104
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3211
Practice Address - Country:US
Practice Address - Phone:516-400-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYP112152103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY215166374OtherDRIVERS LICENSE