Provider Demographics
NPI:1417003732
Name:GRENARD, GWEN R (LCSW-R)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:R
Last Name:GRENARD
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1114
Mailing Address - Country:US
Mailing Address - Phone:516-639-6392
Mailing Address - Fax:516-829-2799
Practice Address - Street 1:505 NORTHERN BLVD
Practice Address - Street 2:STE 103
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5108
Practice Address - Country:US
Practice Address - Phone:516-639-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR048175-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical