Provider Demographics
NPI:1205328010
Name:GROUNDWORK THERAPY PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:GROUNDWORK THERAPY PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:714-267-0471
Mailing Address - Street 1:1000 DEAN STREET,
Mailing Address - Street 2:SUITE 226
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:347-669-9792
Mailing Address - Fax:
Practice Address - Street 1:1000 DEAN STREET,
Practice Address - Street 2:SUITE 226
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:347-669-9792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013167907OtherNPI
1093048753OtherNPI