Healthcare Provider Details

I. General information

NPI: 1588683957
Provider Name (Legal Business Name): MARILYN JEAN GROOT M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 HONOLULU AVE SUITE 180
MONTROSE CA
91020-1853
US

IV. Provider business mailing address

2520 HONOLULU AVE SUITE 180
MONTROSE CA
91020-1853
US

V. Phone/Fax

Practice location:
  • Phone: 818-248-8648
  • Fax: 818-248-7928
Mailing address:
  • Phone: 818-248-8648
  • Fax: 818-248-7928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: