Provider Demographics
NPI:1235203936
Name:GROSS, GERALDINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:GERALDINE
Other - Middle Name:
Other - Last Name:STUVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 GLENCOVE AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4226
Mailing Address - Country:US
Mailing Address - Phone:207-990-5634
Mailing Address - Fax:
Practice Address - Street 1:41 GLENCOVE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4226
Practice Address - Country:US
Practice Address - Phone:207-990-5634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME324660000Medicaid
ME123223OtherANTHEM BLUE CROSS AND BLUE SHIELD OF MAINE