Provider Demographics
NPI:1376838565
Name:GROSS, AMY (MPH, RD, LDN, IBCLC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:MPH, RD, LDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:28156 W NORTHPOINTE PKWY STE 225
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2346
Practice Address - Country:US
Practice Address - Phone:224-512-9800
Practice Address - Fax:224-512-9714
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006525133V00000X, 133V00000X
NCL-49683174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN