Provider Demographics
NPI:1972656296
Name:GROSSMAN, PHYLLIS ANN (MC)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 E CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4348
Mailing Address - Country:US
Mailing Address - Phone:602-410-6635
Mailing Address - Fax:480-609-9552
Practice Address - Street 1:2345 E THOMAS RD
Practice Address - Street 2:SUITE 360
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7848
Practice Address - Country:US
Practice Address - Phone:602-468-2077
Practice Address - Fax:480-609-9688
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC1814101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ964561OtherAHCCS PROVIDER ID