Healthcare Provider Details

I. General information

NPI: 1023415395
Provider Name (Legal Business Name): MICHAEL DEGRUTT LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 11/05/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

1405 SPRUCE ST A
RIVERSIDE CA
92507-2464
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5040
  • Fax:
Mailing address:
  • Phone: 951-715-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: