Provider Demographics
NPI:1629338363
Name:GLOSS, SHELLY M (MSED)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:M
Last Name:GLOSS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 NESBITT RD
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:NY
Mailing Address - Zip Code:14011-9660
Mailing Address - Country:US
Mailing Address - Phone:716-830-3628
Mailing Address - Fax:
Practice Address - Street 1:25 LIBERTY ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3246
Practice Address - Country:US
Practice Address - Phone:585-343-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist