Provider Demographics
NPI:1811343049
Name:DEBRA GRUDA LCSW PC
Entity type:Organization
Organization Name:DEBRA GRUDA LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW R
Authorized Official - Phone:516-729-1530
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 1:475 E MAIN ST
Practice Address - Street 2:SUITE 211
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:516-729-1530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty