Healthcare Provider Details

I. General information

NPI: 1952898496
Provider Name (Legal Business Name): JUDD GRODEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MARION PL
SOUTH HUNTINGTON NY
11746-4718
US

IV. Provider business mailing address

15 MARION PL
SOUTH HUNTINGTON NY
11746-4718
US

V. Phone/Fax

Practice location:
  • Phone: 929-277-9183
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091450-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: