Provider Demographics
NPI:1649683426
Name:JANCOVIC-GRIMM, KATHLEEN (BA,MA,MSW)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:JANCOVIC-GRIMM
Suffix:
Gender:F
Credentials:BA,MA,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5526
Mailing Address - Country:US
Mailing Address - Phone:516-766-1730
Mailing Address - Fax:
Practice Address - Street 1:141 VERNON AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5526
Practice Address - Country:US
Practice Address - Phone:516-766-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist