Provider Demographics
NPI:1669570701
Name:GRODOFSKY-GILMORE, MINDY R
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:R
Last Name:GRODOFSKY-GILMORE
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 1:275 TURNPIKE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2357
Mailing Address - Country:US
Mailing Address - Phone:781-821-1626
Mailing Address - Fax:781-821-1743
Practice Address - Street 1:275 TURNPIKE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2357
Practice Address - Country:US
Practice Address - Phone:781-821-1626
Practice Address - Fax:781-821-1743
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1059441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO6049Medicare ID - Type UnspecifiedMEDICARE