Provider Demographics
NPI:1104800119
Name:GROSS, MARISA (CCC-LSP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:CCC-LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 COMMERCE BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DICKSON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18519-1677
Mailing Address - Country:US
Mailing Address - Phone:570-489-5561
Mailing Address - Fax:570-489-5563
Practice Address - Street 1:851 COMMERCE BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1677
Practice Address - Country:US
Practice Address - Phone:570-489-5561
Practice Address - Fax:570-489-5563
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005969 L225400000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA819172OtherFIRST PRIORITY/BC/BS
PA0018620480005Medicaid
PA9222541OtherPHCS
PA1353701OtherHIGHMARK
PA163624OtherMEDPLUS
PA2787821OtherAETNA HMO
PA7064341OtherAETNA PPO