Provider Demographics
NPI:1164575486
Name:GROSSMAN, JON BIRDELL (MSW)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:BIRDELL
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 E CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4348
Mailing Address - Country:US
Mailing Address - Phone:602-410-6637
Mailing Address - Fax:480-609-9552
Practice Address - Street 1:1300 N 12TH ST STE 550
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2820
Practice Address - Country:US
Practice Address - Phone:602-410-6637
Practice Address - Fax:480-609-9552
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT0182106H00000X
AZLCSW07541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ964579OtherAHCCS PROVIDER ID