Provider Demographics
NPI:1104881812
Name:GROSS, ELIZABETH (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1925
Mailing Address - Country:US
Mailing Address - Phone:860-599-0819
Mailing Address - Fax:860-599-0871
Practice Address - Street 1:158 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1925
Practice Address - Country:US
Practice Address - Phone:860-599-0819
Practice Address - Fax:860-599-0871
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076570Medicare ID - Type Unspecified