Provider Demographics
NPI:1215362579
Name:GROSS, THERESA M (STNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:GROSS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MACKENZIE CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4543
Mailing Address - Country:US
Mailing Address - Phone:567-395-3162
Mailing Address - Fax:
Practice Address - Street 1:9 MACKENZIE CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4543
Practice Address - Country:US
Practice Address - Phone:567-395-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401061410310374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide