Provider Demographics
NPI:1164701751
Name:GROSS, DANIEL R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:GROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 S BRISTOL ST
Mailing Address - Street 2:#459
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7426
Mailing Address - Country:US
Mailing Address - Phone:800-577-4701
Mailing Address - Fax:
Practice Address - Street 1:1155 W GROVE PKWY
Practice Address - Street 2:APT. 329
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-4409
Practice Address - Country:US
Practice Address - Phone:800-577-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4523103T00000X
WAPY60495640103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist