Provider Demographics
NPI:1386780575
Name:GRUNES, MARK (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRUNES
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 1:5 W 86TH ST
Mailing Address - Street 2:APT 2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3603
Mailing Address - Country:US
Mailing Address - Phone:212-362-7768
Mailing Address - Fax:516-921-8707
Practice Address - Street 1:5 W 86TH ST
Practice Address - Street 2:APT 2C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3603
Practice Address - Country:US
Practice Address - Phone:212-362-7768
Practice Address - Fax:516-921-8707
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000393103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV64951Medicare ID - Type UnspecifiedEMPIRE MEDICARE