Healthcare Provider Details

I. General information

NPI: 1164984498
Provider Name (Legal Business Name): GRACE MROZ NP IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE BUILDING 4 SUITE 11
PATCHOGUE NY
11772
US

IV. Provider business mailing address

450 WAVERLY AVE BUILDING 4 SUITE 11
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-730-7503
  • Fax: 631-307-9422
Mailing address:
  • Phone: 631-730-7503
  • Fax: 631-307-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: GRACE MROZ
Title or Position: OWNER
Credential:
Phone: 631-730-7503