Provider Demographics
NPI:1164701074
Name:GROSS, KIMBERLEE B (MA, CCC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEE
Middle Name:B
Last Name:GROSS
Suffix:
Gender:F
Credentials:MA, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 STATION PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3341
Mailing Address - Country:US
Mailing Address - Phone:763-755-4275
Mailing Address - Fax:763-755-4261
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3341
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:763-755-4261
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8562235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist