Provider Demographics
NPI:1265429682
Name:GROSSMAN, MOLLY C (PHD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:C
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 1:708 EAGLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285
Mailing Address - Country:US
Mailing Address - Phone:941-486-1628
Mailing Address - Fax:
Practice Address - Street 1:1700 EDUCATION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950
Practice Address - Country:US
Practice Address - Phone:941-639-8300
Practice Address - Fax:941-639-6831
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4722103TC0700X
FLPY7456103TC0700X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768242500Medicaid