Provider Demographics
NPI:1245240183
Name:GROSS, PATRICIA L (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:GROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21555 BURBANK BLVD. #41
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-5631
Mailing Address - Country:US
Mailing Address - Phone:805-358-7996
Mailing Address - Fax:818-912-6353
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:805-334-5576
Practice Address - Fax:818-912-6353
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9774103G00000X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB237315Medicare PIN