Provider Demographics
NPI:1912689720
Name:GRODIN, STACI
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:GRODIN
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 1:214 HOMMOCKS RD
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3915
Mailing Address - Country:US
Mailing Address - Phone:917-693-8713
Mailing Address - Fax:
Practice Address - Street 1:214 HOMMOCKS RD
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-3915
Practice Address - Country:US
Practice Address - Phone:914-740-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist