=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932479615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAISA GRUDZINSKI LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2012
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 591 STEWART AVE
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-4763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-302-6207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 591 STEWART AVE STE 175
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-4773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-302-6207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 00077061
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------