Provider Demographics
NPI:1720754765
Name:GROWNEY, WILMA MILLER (MFTT)
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:MILLER
Last Name:GROWNEY
Suffix:
Gender:F
Credentials:MFTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2801
Mailing Address - Country:US
Mailing Address - Phone:650-240-3192
Mailing Address - Fax:
Practice Address - Street 1:1021 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2801
Practice Address - Country:US
Practice Address - Phone:650-240-3192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TRAINEE106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist