Healthcare Provider Details

I. General information

NPI: 1962542357
Provider Name (Legal Business Name): GRACE DOROTHY HEDDERMAN MA, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 1ST AVE 14D
NEW YORK NY
10016-8605
US

IV. Provider business mailing address

485 1ST AVE #14D
NEW YORK NY
10016-8605
US

V. Phone/Fax

Practice location:
  • Phone: 212-684-0748
  • Fax: 212-423-7024
Mailing address:
  • Phone: 212-684-0748
  • Fax: 212-423-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: