Provider Demographics
NPI:1457184624
Name:GROSSRUCK, COLLIN (LMFT)
Entity type:Individual
Prefix:MR
First Name:COLLIN
Middle Name:
Last Name:GROSSRUCK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9810 ZIRCON DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3421
Mailing Address - Country:US
Mailing Address - Phone:253-218-7465
Mailing Address - Fax:
Practice Address - Street 1:9810 ZIRCON DR SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98498-3421
Practice Address - Country:US
Practice Address - Phone:253-218-7465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205417106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist