Provider Demographics
NPI:1386782290
Name:GRUNEBAUM, ANDREW MOYER (PHD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MOYER
Last Name:GRUNEBAUM
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 SPOKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1132
Mailing Address - Country:US
Mailing Address - Phone:203-393-0817
Mailing Address - Fax:203-357-9030
Practice Address - Street 1:999 SUMMER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5546
Practice Address - Country:US
Practice Address - Phone:203-324-9712
Practice Address - Fax:203-357-9030
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001760103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4309291OtherAETNA PIN NUMBER
CT060001760CT01OtherANTHEM BLUE CROSS ID
CT6893902OtherGHI-VALUEOPTIONS ID
CT4309291OtherAETNA PIN NUMBER