Provider Demographics
NPI:1952898496
Name:GRODEN, JUDD
Entity Type:Individual
Prefix:
First Name:JUDD
Middle Name:
Last Name:GRODEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MARION PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 MARION PL
Practice Address - Street 2:
Practice Address - City:SOUTH HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11746-4718
Practice Address - Country:US
Practice Address - Phone:929-277-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY091450-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty