Provider Demographics
NPI:1396908661
Name:GROSSBERG, JOHN (PHD MFT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GROSSBERG
Suffix:
Gender:M
Credentials:PHD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94570-6102
Mailing Address - Country:US
Mailing Address - Phone:415-970-1020
Mailing Address - Fax:
Practice Address - Street 1:4112 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3615
Practice Address - Country:US
Practice Address - Phone:415-970-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34782106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist