Provider Demographics
NPI:1386397909
Name:GRODMAN, ERIC MAXIMILIAN
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MAXIMILIAN
Last Name:GRODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 PENBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2062
Mailing Address - Country:US
Mailing Address - Phone:646-761-1970
Mailing Address - Fax:
Practice Address - Street 1:211 THROOP AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5701
Practice Address - Country:US
Practice Address - Phone:718-704-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty