Provider Demographics
NPI:1962154138
Name:GROSECLOSE, BYRON SCOTT
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:SCOTT
Last Name:GROSECLOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GOLDEN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-2712
Mailing Address - Country:US
Mailing Address - Phone:925-354-7285
Mailing Address - Fax:
Practice Address - Street 1:601 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3358
Practice Address - Country:US
Practice Address - Phone:360-281-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty