Provider Demographics
NPI:1578007431
Name:GROSSMAN, ANGEL MANASA
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:MANASA
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HARRIER AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3710
Mailing Address - Country:US
Mailing Address - Phone:831-428-2845
Mailing Address - Fax:
Practice Address - Street 1:120 HARRIER AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3710
Practice Address - Country:US
Practice Address - Phone:831-428-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT108416101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health