Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist | P77977 | NY |
NPI | 1144520768 |
---|---|
Provider Name | Dr. Amanda Lea Grodewald-Adler |
First Address | Centereach, NY 11720-5601 |
Second Address | Centereach, NY 11720-5601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2010 |
Last Update Date | 21/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A300066521 | MEDICARE PTAN (01) | NY |