Provider Demographics
NPI:1881769586
Name:GRAU, MICHAEL JOHN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:GRAU
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:952 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 267
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1608
Mailing Address - Country:US
Mailing Address - Phone:518-469-3110
Mailing Address - Fax:
Practice Address - Street 1:1190 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1026
Practice Address - Country:US
Practice Address - Phone:518-469-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013600103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11324536OtherCAQH