Provider Demographics
NPI:1013201433
Name:GROENEWOLD, SHAY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHAY
Middle Name:L
Last Name:GROENEWOLD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 S MELROSE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6672
Mailing Address - Country:US
Mailing Address - Phone:760-392-1965
Mailing Address - Fax:
Practice Address - Street 1:440 S MELROSE DR STE 250
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6672
Practice Address - Country:US
Practice Address - Phone:760-392-1965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY32538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health