Provider Demographics
NPI:1568580504
Name:GROSS, MICHELLE (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-2010
Mailing Address - Country:US
Mailing Address - Phone:303-857-6688
Mailing Address - Fax:303-857-4156
Practice Address - Street 1:258 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-2010
Practice Address - Country:US
Practice Address - Phone:303-857-6688
Practice Address - Fax:303-857-4156
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07075260Medicaid
CO01007526OtherPETI ID ASHA #
COC1993Medicare PIN