Provider Demographics
NPI:1780467464
Name:GRIJALVA, REBECA
Entity type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:GRIJALVA
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 1:41 UNION SQ W STE 1328
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3252
Mailing Address - Country:US
Mailing Address - Phone:646-470-7109
Mailing Address - Fax:
Practice Address - Street 1:41 UNION SQ W STE 1328
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3252
Practice Address - Country:US
Practice Address - Phone:646-470-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health