Provider Demographics
NPI:1558406660
Name:GROVER, SUSAN (NPP, CS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GROVER
Suffix:
Gender:F
Credentials:NPP, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 SOUND AVE., F11
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-1049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE., SUITE 4
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-886-1194
Practice Address - Fax:631-929-3039
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400636-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2E3301Medicare ID - Type UnspecifiedPROVIDER