Provider Demographics
NPI:1356679716
Name:GROSS, HEIDI ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ELIZABETH
Last Name:GROSS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:ELIZABETH
Other - Last Name:NEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 LIBERTY ST NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3505
Mailing Address - Country:US
Mailing Address - Phone:503-507-3847
Mailing Address - Fax:
Practice Address - Street 1:155 LIBERTY ST NE
Practice Address - Street 2:SUITE 360
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3505
Practice Address - Country:US
Practice Address - Phone:503-507-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist