Provider Demographics
NPI:1811292998
Name:GROSS, CAROL J (BCBA, LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:J
Last Name:GROSS
Suffix:
Gender:F
Credentials:BCBA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2978 E LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-6057
Mailing Address - Country:US
Mailing Address - Phone:801-920-8949
Mailing Address - Fax:
Practice Address - Street 1:2978 E LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-6057
Practice Address - Country:US
Practice Address - Phone:801-920-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
1-09-5651103K00000X
UT5633817-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical