Individual
DR. MARK VINCENT GRUDBERG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
6083 71ST ST, MASPETH, NY 11378-2913
(888) 342-6002
(347) 344-6594
Mailing address
PO BOX 604434, BAYSIDE, NY 11360-4434
(888) 342-6002
(347) 344-6594
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
018098
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03272364
—
NY
Enumeration date
07/22/2009
Last updated
03/05/2012
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