Provider Demographics
NPI:1225575871
Name:GROSS, ISRAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ISRAEL
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 W ROSCOE ST
Mailing Address - Street 2:#4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1056
Mailing Address - Country:US
Mailing Address - Phone:773-879-1392
Mailing Address - Fax:
Practice Address - Street 1:1934 W. ROSCOE ST.
Practice Address - Street 2:#4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-879-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009431103TC0700X, 103TC2200X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent