=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225167489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA LEE GRGURIC LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1540 YORK AVE SUITE 1A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028-5962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-236-9627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 336 E 77TH STREET #8
-----------------------------------------------------
City | NEW YORKQ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-236-9627
-----------------------------------------------------
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 | 001789
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------