Healthcare Provider Details

I. General information

NPI: 1932324191
Provider Name (Legal Business Name): WILLIAM A GRODMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 GEORGETOWN RD
WESTON CT
06883-1525
US

IV. Provider business mailing address

369 GEORGETOWN RD
WESTON CT
06883-1525
US

V. Phone/Fax

Practice location:
  • Phone: 203-221-7908
  • Fax:
Mailing address:
  • Phone: 203-221-7908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number002166
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: