Provider Demographics
NPI:1578528667
Name:GROSSMAN, JONATHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2125
Mailing Address - Country:US
Mailing Address - Phone:631-580-9364
Mailing Address - Fax:631-580-9365
Practice Address - Street 1:1855 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7949
Practice Address - Country:US
Practice Address - Phone:631-580-9364
Practice Address - Fax:631-580-9365
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043922-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02246913Medicaid
NYJG0NG10710Medicare ID - Type Unspecified
NY02246913Medicaid