Provider Demographics
NPI:1932339157
Name:GRUDBERG, MARK VINCENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
Last Name:GRUDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604434
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-4434
Mailing Address - Country:US
Mailing Address - Phone:888-342-6002
Mailing Address - Fax:347-344-6594
Practice Address - Street 1:6083 71ST ST
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2913
Practice Address - Country:US
Practice Address - Phone:888-342-6002
Practice Address - Fax:347-344-6594
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018098103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03272364Medicaid