Provider Demographics
NPI:1043603590
Name:GROSS, ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N LINDEN ST
Mailing Address - Street 2:APT H308
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5321
Mailing Address - Country:US
Mailing Address - Phone:715-579-7194
Mailing Address - Fax:
Practice Address - Street 1:110 HORTON FIELDHOUSE
Practice Address - Street 2:CAMPUS BOX 7130
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-0001
Practice Address - Country:US
Practice Address - Phone:309-438-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0035392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer