MEDICARE: MR. WILLIAM ALFRED DEGROOT III MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MF18816	CA

General Provider Information

NPI Number	:	1871511857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM ALFRED DEGROOT III MFT

Provider Business Mailing Address
First Line	:	1709 FRASER CIRCLE
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-5632
Country	:	US
Telephone Number	:	951-733-4217
Fax Number	:	951-737-6257

Provider Business Practice Location Address
First Line	:	1901 WEST ONTARIO AVE
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-5632
Country	:	US
Telephone Number	:	951-733-4217
Fax Number	:	951-737-6257

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	09/07/2010

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