Healthcare Provider Details

I. General information

NPI: 1225167489
Provider Name (Legal Business Name): CYNTHIA LEE GRGURIC LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 YORK AVE SUITE 1A
NEW YORK NY
10028-5962
US

IV. Provider business mailing address

336 E 77TH STREET #8
NEW YORKQ NY
10021
US

V. Phone/Fax

Practice location:
  • Phone: 646-236-9627
  • Fax:
Mailing address:
  • Phone: 646-236-9627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001789
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: