Provider Demographics
NPI:1477722338
Name:GROSS, HEIDI JOLENE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:HEIDI
Middle Name:JOLENE
Last Name:GROSS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4183 N CLARENDON AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2460
Mailing Address - Country:US
Mailing Address - Phone:773-517-2588
Mailing Address - Fax:
Practice Address - Street 1:319 DEMPSTER ST
Practice Address - Street 2:SUITE 208
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4797
Practice Address - Country:US
Practice Address - Phone:847-733-0169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist