Provider Demographics
NPI:1952360828
Name:GRZEGOREK, ALFRED EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:EDWARD
Last Name:GRZEGOREK
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 1:4466 DARROW RD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1866
Mailing Address - Country:US
Mailing Address - Phone:330-688-6921
Mailing Address - Fax:330-688-4470
Practice Address - Street 1:4466 DARROW RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1866
Practice Address - Country:US
Practice Address - Phone:330-688-6921
Practice Address - Fax:330-688-4470
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1008103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP09953Medicare PIN