Provider Demographics
NPI:1154074714
Name:TINA GROSSMAN, LLC
Entity Type:Organization
Organization Name:TINA GROSSMAN, LLC
Other - Org Name:GOODWELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:302-540-2424
Mailing Address - Street 1:21 HILTON RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4324
Mailing Address - Country:US
Mailing Address - Phone:302-540-2424
Mailing Address - Fax:
Practice Address - Street 1:3510 SILVERSIDE RD STE 2
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4937
Practice Address - Country:US
Practice Address - Phone:484-416-4485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty