Provider Demographics
NPI:1265594329
Name:GROSSMAN, BRUCE M (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:M
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HYSON WAY
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1833
Mailing Address - Country:US
Mailing Address - Phone:631-698-0134
Mailing Address - Fax:
Practice Address - Street 1:6 HYSON WAY
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1833
Practice Address - Country:US
Practice Address - Phone:631-698-0134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0166091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical