MEDICARE: IRA GROSSMAN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY5618	CA

General Provider Information

NPI Number	:	1205969185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRA GROSSMAN PHD

Provider Business Mailing Address
First Line	:	4550 KEARNY VILLA ROAD
Second Line	:	SUITE 214
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1563
Country	:	US
Telephone Number	:	858-560-0900
Fax Number	:	858-560-1266

Provider Business Practice Location Address
First Line	:	4550 KEARNY VILLA ROAD
Second Line	:	SUITE 214
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1563
Country	:	US
Telephone Number	:	858-560-0900
Fax Number	:	858-560-1266

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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Directions to “ IRA GROSSMAN PHD” Practice Location

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