Provider Demographics
NPI:1144520768
Name:GRODEWALD-ADLER, AMANDA LEA (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEA
Last Name:GRODEWALD-ADLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-5601
Mailing Address - Country:US
Mailing Address - Phone:631-209-5343
Mailing Address - Fax:631-648-7655
Practice Address - Street 1:1919 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 308
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-5601
Practice Address - Country:US
Practice Address - Phone:631-209-5343
Practice Address - Fax:631-648-7655
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP77977103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300066521OtherMEDICARE PTAN