Provider Demographics
NPI:1710071279
Name:GROSS, FRED M (PSYD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:GROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3031
Mailing Address - Country:US
Mailing Address - Phone:856-222-1840
Mailing Address - Fax:
Practice Address - Street 1:715 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3031
Practice Address - Country:US
Practice Address - Phone:856-222-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00302000103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist