Provider Demographics
NPI:1528867504
Name:GROSS, EVAN ZACHARY (PHD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ZACHARY
Last Name:GROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21546 GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3006
Mailing Address - Country:US
Mailing Address - Phone:201-403-4977
Mailing Address - Fax:
Practice Address - Street 1:250 W EISENHOWER PKWY STE 190
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6934
Practice Address - Country:US
Practice Address - Phone:734-961-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018995103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist