Provider Demographics
NPI:1013093590
Name:GRODMAN, SUSAN M (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:GRODMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MIRIAM
Other - Last Name:MYDLARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:85 PENBROKE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2062
Mailing Address - Country:US
Mailing Address - Phone:718-447-7520
Mailing Address - Fax:
Practice Address - Street 1:19 WEST 34TH STREET
Practice Address - Street 2:PH LEVEL 13TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:917-747-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013866103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VM3591Medicare ID - Type Unspecified