Provider Demographics
NPI:1316107873
Name:GRABAU, MARK ALLAN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:GRABAU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1899 E ROSEVILLE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7980
Mailing Address - Country:US
Mailing Address - Phone:916-220-4527
Mailing Address - Fax:916-771-5353
Practice Address - Street 1:1899 E ROSEVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7980
Practice Address - Country:US
Practice Address - Phone:916-220-4527
Practice Address - Fax:916-771-5353
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18761103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA354461OtherMHN
CAOPL187610Medicare UPIN