Provider Demographics
NPI:1417530577
Name:GROSJEAN, RYAN (MFT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GROSJEAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 N MOUNTAIN AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4173
Mailing Address - Country:US
Mailing Address - Phone:909-781-0250
Mailing Address - Fax:
Practice Address - Street 1:870 N MOUNTAIN AVE STE 206
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4173
Practice Address - Country:US
Practice Address - Phone:909-781-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist