Provider Demographics
NPI:1649889189
Name:GRISAR, CARLY DANIELLE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:DANIELLE
Last Name:GRISAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4817
Mailing Address - Country:US
Mailing Address - Phone:516-491-8119
Mailing Address - Fax:
Practice Address - Street 1:1560 MAYFLOWER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5400
Practice Address - Country:US
Practice Address - Phone:718-948-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist