Healthcare Provider Details

I. General information

NPI: 1972819084
Provider Name (Legal Business Name): MR. CARL GRASSO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31413 N 20TH AVE
PHOENIX AZ
85085-7021
US

IV. Provider business mailing address

31413 N 20TH AVE
PHOENIX AZ
85085-7021
US

V. Phone/Fax

Practice location:
  • Phone: 623-398-5840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3696312
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: