Provider Demographics
NPI:1588683957
Name:GROOT, MARILYN JEAN (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:JEAN
Last Name:GROOT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 HONOLULU AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1853
Mailing Address - Country:US
Mailing Address - Phone:818-248-8648
Mailing Address - Fax:818-248-7928
Practice Address - Street 1:2520 HONOLULU AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1853
Practice Address - Country:US
Practice Address - Phone:818-248-8648
Practice Address - Fax:818-248-7928
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1624231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0016240Medicaid
AUD1624Medicare ID - Type Unspecified