Provider Demographics
NPI:1649458548
Name:GRUDA, DEBRA LAUREN (LCSWR)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:LAUREN
Last Name:GRUDA
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:MRS
Other - First Name:DEBRA
Other - Middle Name:LAUREN
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0732
Mailing Address - Country:US
Mailing Address - Phone:516-729-1530
Mailing Address - Fax:
Practice Address - Street 1:26 SPENCER ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3131
Practice Address - Country:US
Practice Address - Phone:516-729-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071391104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker