Provider Demographics
NPI:1265442248
Name:GROSS, RUTH DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:DIANE
Last Name:GROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1201 CHELSEA WAY
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3666
Mailing Address - Country:US
Mailing Address - Phone:650-363-8090
Mailing Address - Fax:650-363-8090
Practice Address - Street 1:1220 UNIVERSITY DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4265
Practice Address - Country:US
Practice Address - Phone:650-361-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL152810Medicare ID - Type Unspecified