Provider Demographics
NPI:1588674857
Name:GROSSMAN, BRUCE (LPCC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 KIT CARSON RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6452
Mailing Address - Country:US
Mailing Address - Phone:505-758-7835
Mailing Address - Fax:505-758-7835
Practice Address - Street 1:631 KIT CARSON RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6452
Practice Address - Country:US
Practice Address - Phone:505-758-7835
Practice Address - Fax:505-758-7835
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM190101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health