Healthcare Provider Details

I. General information

NPI: 1932078318
Provider Name (Legal Business Name): RUSSELL GROENHEIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 CITRUS AVE
FONTANA CA
92335-5571
US

IV. Provider business mailing address

9680 CITRUS AVE
FONTANA CA
92335-5571
US

V. Phone/Fax

Practice location:
  • Phone: 909-357-5000
  • Fax: 909-357-7699
Mailing address:
  • Phone: 909-357-5000
  • Fax: 909-357-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number170247625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: