Provider Demographics
NPI:1164838983
Name:GROSS, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 VILLAGE VIEW DRIVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-743-7252
Mailing Address - Fax:
Practice Address - Street 1:161 VILLAGE VIEW DRIVE
Practice Address - Street 2:SUITE 403
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-743-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASP9252SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist