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General NPI Number Information
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NPI Number | 1932339157
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Entity Type | Individual
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Provider Name | MARK VINCENT GRUDBERG PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/22/2009
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Last Update Date | 03/05/2012
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Provider Practice Location Address
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Address Line | 6083 71ST ST
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City | MASPETH
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State | NY
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Zip | 11378-2913
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Country | US
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Telephone | 888-342-6002
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Fax | 347-344-6594
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Provider Business Mailing Address
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Address Line | PO BOX 604434
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City | BAYSIDE
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State | NY
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Zip | 11360-4434
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Country | US
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Telephone | 888-342-6002
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Fax | 347-344-6594
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 018098
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License Number State | NY
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