Provider Demographics
NPI:1295572162
Name:BOURESTON GROSSMAN, DIANE MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BOURESTON GROSSMAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 HARTZELL ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3817
Mailing Address - Country:US
Mailing Address - Phone:310-383-0037
Mailing Address - Fax:
Practice Address - Street 1:871 HARTZELL ST
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3817
Practice Address - Country:US
Practice Address - Phone:310-383-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT20852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty