Provider Demographics
NPI:1619446721
Name:GRUNENBERG, ALESSIA (LCSW)
Entity Type:Individual
Prefix:
First Name:ALESSIA
Middle Name:
Last Name:GRUNENBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALESSIA
Other - Middle Name:
Other - Last Name:RUSSELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15449 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3829
Mailing Address - Country:US
Mailing Address - Phone:718-309-0405
Mailing Address - Fax:
Practice Address - Street 1:3109 37TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3932
Practice Address - Country:US
Practice Address - Phone:718-721-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104756104100000X
NY0942661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY819636228OtherDRIVER LICENSE