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General NPI Number Information
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NPI Number | 1013093590
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Entity Type | Individual
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Provider Name | SUSAN M GRODMAN PHD
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Gender | Female
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 10/03/2012
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Provider Practice Location Address
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Address Line | 19 WEST 34TH STREET PH LEVEL 13TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10001-3006
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Country | US
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Telephone | 917-747-2430
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Fax |
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Provider Business Mailing Address
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Address Line | 85 PENBROKE AVENUE
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City | STATEN ISLAND
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State | NY
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Zip | 10301-2062
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Country | US
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Telephone | 718-447-7520
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 013866
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License Number State | NY
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