Provider Demographics
NPI:1679820716
Name:GROSS, ELIZABETH A (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:GROSS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:MELCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1439 CHURCHILL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2089
Mailing Address - Country:US
Mailing Address - Phone:715-258-7778
Mailing Address - Fax:715-258-7773
Practice Address - Street 1:1948 GODFREY DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-7908
Practice Address - Country:US
Practice Address - Phone:715-258-7778
Practice Address - Fax:715-258-7773
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12023-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679820716Medicaid
WI12023-24OtherSTATE LICENSING