Provider Demographics
NPI:1205254018
Name:GRZYMALA, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GRZYMALA
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 1:2001 FOXGLOVE CIR
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-3073
Mailing Address - Country:US
Mailing Address - Phone:631-897-0117
Mailing Address - Fax:
Practice Address - Street 1:35 LONGWOOD ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953
Practice Address - Country:US
Practice Address - Phone:631-924-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator