Provider Demographics
NPI:1508308099
Name:GROSS, TERESA (LPC, SACIT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:LPC, SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N LYNNDALE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3056
Mailing Address - Country:US
Mailing Address - Phone:920-735-9010
Mailing Address - Fax:920-735-9050
Practice Address - Street 1:1000 N LYNNDALE DR
Practice Address - Street 2:SUITE C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3056
Practice Address - Country:US
Practice Address - Phone:920-735-9010
Practice Address - Fax:920-735-9050
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17985-130101YA0400X
WI6296-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)