Healthcare Provider Details

I. General information

NPI: 1619948254
Provider Name (Legal Business Name): DANA THISTED GROSSMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY11604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: