Provider Demographics
NPI:1386910347
Name:PEDIATRIC PSYCHOLOGY OF NEW YORK, PLLC
Entity type:Organization
Organization Name:PEDIATRIC PSYCHOLOGY OF NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:GRUDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:888-342-6002
Mailing Address - Street 1:PO BOX 604434
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-4434
Mailing Address - Country:US
Mailing Address - Phone:888-342-6002
Mailing Address - Fax:347-344-6594
Practice Address - Street 1:6083 71ST ST
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2913
Practice Address - Country:US
Practice Address - Phone:888-342-6002
Practice Address - Fax:347-344-6594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018098103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty