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General NPI Number Information
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NPI Number | 1104102334
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Entity Type | Individual
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Provider Name | GRACE ANN REYNOLDS VICTOR LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/02/2011
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Last Update Date | 09/30/2014
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Provider Practice Location Address
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Address Line | 28 WOOD RD
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City | CENTEREACH
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State | NY
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Zip | 11720-1620
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Country | US
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Telephone | 631-471-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 28 WOOD RD
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City | CENTEREACH
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State | NY
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Zip | 11720-1620
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Country | US
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Telephone | 631-471-6400
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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 | 1041S0200X
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Taxonomy Name | School Social Worker
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License Number | R080813-1
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License Number State | NY
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