Provider Demographics
NPI:1386296846
Name:GROSS, MICHELLE (MA, LBS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:MA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 OLD EAGLE SCHOOL RD STE 1206
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:998 OLD EAGLE SCHOOL RD STE 1206
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1805
Practice Address - Country:US
Practice Address - Phone:215-219-0233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003882103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH003882OtherBEHAVIOR SPECIALIST LICENSE