Provider Demographics
NPI:1508377185
Name:BERLEY GROSS, MICHELLE LAUREN (MS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAUREN
Last Name:BERLEY GROSS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 TAMANINI DR
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-9371
Mailing Address - Country:US
Mailing Address - Phone:570-814-7076
Mailing Address - Fax:
Practice Address - Street 1:193 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-846-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003587103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst