Provider Demographics
NPI:1376796243
Name:GROSSBERG, REVA HILLARY
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:HILLARY
Last Name:GROSSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 TEMPLE CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1212
Mailing Address - Country:US
Mailing Address - Phone:347-563-5820
Mailing Address - Fax:
Practice Address - Street 1:24 TEMPLE CT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-1212
Practice Address - Country:US
Practice Address - Phone:347-563-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05347-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist