Provider Demographics
NPI:1053082388
Name:GROSSMAN, KATRINA MAILE (MFT)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:MAILE
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2813
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-2813
Mailing Address - Country:US
Mailing Address - Phone:703-634-9675
Mailing Address - Fax:
Practice Address - Street 1:13036 FROSTY LN
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4916
Practice Address - Country:US
Practice Address - Phone:703-634-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health