| Organization Name: | PEDIATRIC PSYCHOLOGY OF NEW YORK, PLLC |
| NPI Number: | 1386910347 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARK VINCENT GRUDBERG (MEMBER) |
| Mailing Address: | 6083 71st St Maspeth |
| State: | NY US |
| Postal Code: | 113782913 |
| Phone Number: | 8883426002 |
| Fax Number: | 3473446594 |
| NPI Enumeration Date: | 03/23/2012 |
| NPI Last Update Date: | 03/23/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 018098 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |