Provider Demographics
NPI:1194118844
Name:GRUSSGOTT, REBECCA (MA SLP)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:GRUSSGOTT
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BARACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA SLP
Mailing Address - Street 1:320 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-3303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 W 21ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-3303
Practice Address - Country:US
Practice Address - Phone:212-929-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY208311672Medicaid