Healthcare Provider Details

I. General information

NPI: 1891857975
Provider Name (Legal Business Name): DAVID GRODEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MARION PL
HUNTINGTON STATION NY
11746-4718
US

IV. Provider business mailing address

15 MARION PL
HUNTINGTON STATION NY
11746-4718
US

V. Phone/Fax

Practice location:
  • Phone: 631-673-7237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number022729R
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number022729R
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: