Provider Demographics
NPI:1063695112
Name:GROSSMAN, RICHARD (BA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 SW MCCLELLEN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6135
Mailing Address - Country:US
Mailing Address - Phone:772-336-7516
Mailing Address - Fax:772-336-7516
Practice Address - Street 1:4209 SW MCCLELLEN ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6135
Practice Address - Country:US
Practice Address - Phone:772-336-7516
Practice Address - Fax:772-336-7516
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator