Provider Demographics
NPI:1558919936
Name:GROSS, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6585 KY 30 E
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41314
Mailing Address - Country:US
Mailing Address - Phone:606-493-6268
Mailing Address - Fax:
Practice Address - Street 1:6585 KY 30 E
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41314
Practice Address - Country:US
Practice Address - Phone:606-493-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist