Provider Demographics
NPI:1679872295
Name:GRUNDER, LAURA VANESA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:VANESA
Last Name:GRUNDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34-43 60TH STREET
Mailing Address - Street 2:APT 4J
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2120
Mailing Address - Country:US
Mailing Address - Phone:718-505-1482
Mailing Address - Fax:
Practice Address - Street 1:1825 BATH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4613
Practice Address - Country:US
Practice Address - Phone:718-238-4637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007850-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant