Provider Demographics
NPI:1558428631
Name:GROSSMAN, RICHARD (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 THORNDIKE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5845
Mailing Address - Country:US
Mailing Address - Phone:617-277-4449
Mailing Address - Fax:
Practice Address - Street 1:122 THORNDIKE ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5845
Practice Address - Country:US
Practice Address - Phone:617-277-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03562Medicare ID - Type Unspecified