Provider Demographics
NPI:1093838088
Name:GROTH-MARNAT, GARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:GROTH-MARNAT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 HOLLISTER RANCH RD
Mailing Address - Street 2:
Mailing Address - City:GAVIOTA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-9751
Mailing Address - Country:US
Mailing Address - Phone:805-698-7817
Mailing Address - Fax:
Practice Address - Street 1:98 HOLLISTER RANCH RD
Practice Address - Street 2:
Practice Address - City:GAVIOTA
Practice Address - State:CA
Practice Address - Zip Code:93117-9751
Practice Address - Country:US
Practice Address - Phone:805-698-7817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6686103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical