Healthcare Provider Details

I. General information

NPI: 1306917893
Provider Name (Legal Business Name): JUDY A GROSSMAN-EULAU CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80TH ST & 41ST AVE
ELMHURST NY
11373
US

IV. Provider business mailing address

225 MAIN ST. MANAGED CARE, D1-01
PORT WASHINGTON NY
11050-3211
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-3900
  • Fax: 718-334-5958
Mailing address:
  • Phone: 516-767-1133
  • Fax: 516-767-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18538
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000376
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: