Provider Demographics
NPI:1144417536
Name:GROS, MARY W (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:GROS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:W
Other - Last Name:GROS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4955 HYDE CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-5240
Mailing Address - Country:US
Mailing Address - Phone:770-521-0110
Mailing Address - Fax:
Practice Address - Street 1:131 ROSWELL ST
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-1996
Practice Address - Country:US
Practice Address - Phone:770-521-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000094225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist