Healthcare Provider Details

I. General information

NPI: 1649458548
Provider Name (Legal Business Name): DEBRA LAUREN GRUDA LCSWR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEBRA LAUREN FORMAN LMSW

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SPENCER ST
FARMINGDALE NY
11735-3131
US

IV. Provider business mailing address

PO BOX 732
MASSAPEQUA PARK NY
11762-0732
US

V. Phone/Fax

Practice location:
  • Phone: 516-729-1530
  • Fax:
Mailing address:
  • Phone: 516-729-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number071391
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: