Basic Information
| Provider Information | |||||||||
| NPI: | 1609223148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRODNER | ||||||||
| FirstName: | MARC | ||||||||
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| Credential: | RADT I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 SAN LUIS CIR UNIT 729 | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940143639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133742266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941031600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154873000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2016 | ||||||||
| LastUpdateDate: | 05/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | R1192780215 | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.