Provider Demographics
NPI:1598359390
Name:DEGRAND, EDDIE
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:DEGRAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 WASHINGTON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-3637
Mailing Address - Country:US
Mailing Address - Phone:312-636-0227
Mailing Address - Fax:
Practice Address - Street 1:40 EXCHANGE PL STE 1700
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-2700
Practice Address - Country:US
Practice Address - Phone:312-636-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0980471041C0700X
NY102567104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker