Healthcare Provider Details

I. General information

NPI: 1407885072
Provider Name (Legal Business Name): DEBRA ANN GROSSANO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 RIVER RD SUITE 106
EDGEWATER NJ
07020-1171
US

IV. Provider business mailing address

446 RADCLIFFE ST
WYCKOFF NJ
07481-3062
US

V. Phone/Fax

Practice location:
  • Phone: 201-615-9139
  • Fax: 866-391-3047
Mailing address:
  • Phone: 201-615-9139
  • Fax: 866-391-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005443
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: