Basic Information
| Provider Information | |||||||||
| NPI: | 1265696587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAZINA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALLO | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 HARRYS LN | ||||||||
| Address2: | |||||||||
| City: | SAG HARBOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119631509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318993353 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 66 NEWTOWN LN | ||||||||
| Address2: | |||||||||
| City: | EAST HAMPTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119372440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313243344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 072986 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.