Provider Demographics
NPI:1306917893
Name:GROSSMAN-EULAU, JUDY A (CASAC)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:GROSSMAN-EULAU
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN ST.
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3211
Mailing Address - Country:US
Mailing Address - Phone:516-767-1133
Mailing Address - Fax:516-767-3680
Practice Address - Street 1:80TH ST & 41ST AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-3900
Practice Address - Fax:718-334-5958
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000376221700000X
NY18538101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid