Provider Demographics
NPI:1962773341
Name:GRANDE, GINA (MA)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:GRANDE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:LATTANZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:19 ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6105
Mailing Address - Country:US
Mailing Address - Phone:631-796-0038
Mailing Address - Fax:
Practice Address - Street 1:320 FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-3309
Practice Address - Country:US
Practice Address - Phone:631-872-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist