Healthcare Provider Details

I. General information

NPI: 1285642686
Provider Name (Legal Business Name): KATHLEEN LINEHAN GRAMBLING PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 12TH AVE
BROOKLYN NY
11219-3424
US

IV. Provider business mailing address

273 CHESTNUT HILL RD
STONE RIDGE NY
12484-5521
US

V. Phone/Fax

Practice location:
  • Phone: 800-275-3243
  • Fax: 800-275-3671
Mailing address:
  • Phone: 845-687-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number008848
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: