Provider Demographics
NPI:1134630759
Name:GRUCCI, LAUREN E
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:GRUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BELLPORT LN
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2751
Mailing Address - Country:US
Mailing Address - Phone:631-681-2317
Mailing Address - Fax:
Practice Address - Street 1:939 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6066
Practice Address - Country:US
Practice Address - Phone:631-681-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0927841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical