Provider Demographics
NPI:1043549900
Name:GRODNITZKY, GUSTAVO RAFAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:RAFAEL
Last Name:GRODNITZKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 MITCH DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5126
Mailing Address - Country:US
Mailing Address - Phone:336-659-8058
Mailing Address - Fax:
Practice Address - Street 1:736 MITCH DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-5126
Practice Address - Country:US
Practice Address - Phone:336-659-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2810103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist