Provider Demographics
NPI:1932324191
Name:GRODMAN, WILLIAM A (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:GRODMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1525
Mailing Address - Country:US
Mailing Address - Phone:203-221-7908
Mailing Address - Fax:
Practice Address - Street 1:369 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:CT
Practice Address - Zip Code:06883-1525
Practice Address - Country:US
Practice Address - Phone:203-221-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002166103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002166CT01OtherBLUE CROSS
CT680001182Medicare ID - Type Unspecified