Provider Demographics
NPI:1629145784
Name:GROSS, AMY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:BETH
Last Name:GROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6834 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1021
Mailing Address - Country:US
Mailing Address - Phone:315-446-3292
Mailing Address - Fax:315-329-0161
Practice Address - Street 1:6834 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1021
Practice Address - Country:US
Practice Address - Phone:315-446-3292
Practice Address - Fax:315-329-0161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011965103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent