Provider Demographics
NPI:1356903231
Name:GROVES ROSSI, MARY LESLIE (BC-DMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LESLIE
Last Name:GROVES ROSSI
Suffix:
Gender:F
Credentials:BC-DMT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LESLIE
Other - Last Name:GROVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BC-DMT
Mailing Address - Street 1:420 GILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8009
Mailing Address - Country:US
Mailing Address - Phone:707-655-3420
Mailing Address - Fax:
Practice Address - Street 1:3419 VALLE VERDE DR # 707
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-299-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC7459101Y00000X
CA225600000X
CAAMFT117176106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Single Specialty