Provider Demographics
NPI:1225632110
Name:GROSE, JUSTIN LEE (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LEE
Last Name:GROSE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6344 E COUNTY ROAD 500 N
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:IN
Mailing Address - Zip Code:47615-9434
Mailing Address - Country:US
Mailing Address - Phone:812-719-6143
Mailing Address - Fax:
Practice Address - Street 1:629 INGLE ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1345
Practice Address - Country:US
Practice Address - Phone:812-602-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010999A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health