Provider Demographics
NPI:1316013774
Name:GLOSS, BETTY JEAN
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JEAN
Last Name:GLOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5220
Mailing Address - Country:US
Mailing Address - Phone:607-229-7660
Mailing Address - Fax:
Practice Address - Street 1:408 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5220
Practice Address - Country:US
Practice Address - Phone:607-229-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0760291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid