Provider Demographics
NPI:1285709295
Name:IMAROGBE GRANTHAM, KAMAU I (PH D)
Entity type:Individual
Prefix:DR
First Name:KAMAU
Middle Name:I
Last Name:IMAROGBE GRANTHAM
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11402 GUY R BREWER BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1234
Mailing Address - Country:US
Mailing Address - Phone:718-883-6650
Mailing Address - Fax:718-883-6669
Practice Address - Street 1:11402 GUY R BREWER BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1234
Practice Address - Country:US
Practice Address - Phone:718-883-6650
Practice Address - Fax:718-883-6669
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 016333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid