Provider Demographics
NPI:1417647603
Name:GROSSMAN, MATTHEW I
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:I
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 W CHEYENNE AVE STE 100-130
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-8212
Mailing Address - Country:US
Mailing Address - Phone:702-331-1917
Mailing Address - Fax:702-331-5219
Practice Address - Street 1:3550 W CHEYENNE AVE STE 100-130
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-8212
Practice Address - Country:US
Practice Address - Phone:702-331-1917
Practice Address - Fax:702-331-5219
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician