Provider Demographics
NPI:1619688074
Name:GROSSMAN, MAX JACOB
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:JACOB
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 NE PATRICK LN
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4849
Mailing Address - Country:US
Mailing Address - Phone:360-720-0061
Mailing Address - Fax:
Practice Address - Street 1:1234 NE PATRICK LN
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4849
Practice Address - Country:US
Practice Address - Phone:360-720-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA100582328WAMedicaid