=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811198906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE JOSEPH GROSSO PHD PSYCH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 03/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24100 SORREL COURT
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-822-9011
-----------------------------------------------------
Fax | 661-822-0476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24100 SORREL COURT
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-822-9011
-----------------------------------------------------
Fax | 661-822-0476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY10108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY10108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PSY10108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------