Provider Demographics
NPI:1730175878
Name:GRUCELA, IRIS A (PT)
Entity type:Individual
Prefix:MRS
First Name:IRIS
Middle Name:A
Last Name:GRUCELA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:IRIS
Other - Middle Name:A
Other - Last Name:HOROWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:800 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5314
Mailing Address - Country:US
Mailing Address - Phone:516-829-8450
Mailing Address - Fax:516-829-8452
Practice Address - Street 1:800 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5314
Practice Address - Country:US
Practice Address - Phone:516-829-8450
Practice Address - Fax:516-829-8452
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ73241OtherBCBS
NYQ73241OtherBCBS