Provider Demographics
NPI:1366533754
Name:ORENBAKH, GRIGORY (PHD)
Entity type:Individual
Prefix:
First Name:GRIGORY
Middle Name:
Last Name:ORENBAKH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 NEWBURG AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3107
Mailing Address - Country:US
Mailing Address - Phone:917-657-0290
Mailing Address - Fax:
Practice Address - Street 1:821 NEWBURG AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3107
Practice Address - Country:US
Practice Address - Phone:917-657-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014896103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02204608Medicaid
NYVL4961Medicare ID - Type Unspecified