Provider Demographics
NPI:1578581849
Name:GROSSMAN, DALE ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:ELLEN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2016
Mailing Address - Country:US
Mailing Address - Phone:651-341-5296
Mailing Address - Fax:
Practice Address - Street 1:521 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2016
Practice Address - Country:US
Practice Address - Phone:651-341-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical