Provider Demographics
NPI:1922511401
Name:GROTLISCH, CHRISTIANA DORIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTIANA
Middle Name:DORIAN
Last Name:GROTLISCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31450 BROAD BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-2669
Mailing Address - Country:US
Mailing Address - Phone:310-499-3145
Mailing Address - Fax:
Practice Address - Street 1:31450 BROAD BEACH RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2669
Practice Address - Country:US
Practice Address - Phone:310-881-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA98118101YM0800X
CA1153051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health