Provider Demographics
NPI:1356462931
Name:GROSSMAN, ROSS KENNETH (LMFT)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:KENNETH
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N SYCAMORE AVE APT 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2947
Mailing Address - Country:US
Mailing Address - Phone:323-525-0577
Mailing Address - Fax:
Practice Address - Street 1:5455 WILSHIRE BLVD
Practice Address - Street 2:1010
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4201
Practice Address - Country:US
Practice Address - Phone:323-646-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 31086106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007300Medicaid
CASUBB937OtherLA DMH PROVIDER
CA00007570Medicaid