Provider Demographics
NPI:1336596147
Name:GRONEVELDT, TOBIAS
Entity Type:Individual
Prefix:
First Name:TOBIAS
Middle Name:
Last Name:GRONEVELDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 209TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1127
Mailing Address - Country:US
Mailing Address - Phone:718-877-7976
Mailing Address - Fax:718-423-6617
Practice Address - Street 1:1585 209TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1127
Practice Address - Country:US
Practice Address - Phone:718-877-7976
Practice Address - Fax:718-423-6617
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-21
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1558732420Medicaid
NY1558732420Medicare UPIN
NY1558732420Medicaid
NY1558732420Medicare NSC
NY1558732420Medicare Oscar/Certification