=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093282774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADAV ANTEBI-GRUSZKA PHD, MHC-LP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2018
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 W 24TH ST STE 1002
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-770-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 FORT WASHINGTON AVE APT 21
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-1310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-280-5557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | P13871
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------