Provider Demographics
NPI:1114085107
Name:GROSS, SAMUEL P (MALLP, LPC, CSW)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:P
Last Name:GROSS
Suffix:
Gender:M
Credentials:MALLP, LPC, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16991 DUBLAINE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-433-1069
Mailing Address - Fax:
Practice Address - Street 1:53950 VAN DYKE AVE
Practice Address - Street 2:SUITE 210B
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1819
Practice Address - Country:US
Practice Address - Phone:586-781-8400
Practice Address - Fax:586-781-8300
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801057702103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical