Provider Demographics
NPI:1467525659
Name:GROSS, BONNIE L (MS, MA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:GROSS
Suffix:
Gender:F
Credentials:MS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-2246
Mailing Address - Country:US
Mailing Address - Phone:814-827-6648
Mailing Address - Fax:814-827-0206
Practice Address - Street 1:452 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-2246
Practice Address - Country:US
Practice Address - Phone:814-827-6648
Practice Address - Fax:814-827-0206
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009990101YP2500X
PAAT000179-L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01651983Medicaid
PA236611Medicare ID - Type Unspecified
PA01651983Medicaid