Provider Demographics
NPI:1447388137
Name:GROSSMAN, LAURA (SW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 CANDELARIA RD NE
Mailing Address - Street 2:SANDIA HS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3757
Mailing Address - Country:US
Mailing Address - Phone:505-294-1511
Mailing Address - Fax:
Practice Address - Street 1:5341 WYOMING BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3164
Practice Address - Country:US
Practice Address - Phone:505-508-0197
Practice Address - Fax:505-508-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 5638104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21253790Medicaid