Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 003899 | NY |
NPI | 1245540178 |
---|---|
Provider Name | Mr. Badri Anthony Gravesande |
First Address | Staten Island, NY 10304-2604 |
Second Address | Staten Island, NY 10304-2604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2010 |
Last Update Date | 13/10/2010 |