Provider Demographics
NPI:1962967521
Name:GROSS, TERESA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:GROSS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12403 MELLOW MEADOW DR APT 19105
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1960
Mailing Address - Country:US
Mailing Address - Phone:512-203-4940
Mailing Address - Fax:
Practice Address - Street 1:9501 N CAPITAL OF TEXAS HWY STE 103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-7254
Practice Address - Country:US
Practice Address - Phone:512-578-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992187702OtherGROUP MENTAL HEALTH PRACTICE