Basic Information
Provider Information
NPI: 1033556428
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GROSSMAYER
FirstName: JUSTIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2459 S CONGRESS AVE STE 100
Address2:  
City: PALM SPRINGS
State: FL
PostalCode: 334067616
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2459 S CONGRESS AVE STE 100
Address2:  
City: PALM SPRINGS
State: FL
PostalCode: 334067616
CountryCode: US
TelephoneNumber: 5614715111
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/27/2013
LastUpdateDate: 07/21/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XSW11054FLY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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