Provider Demographics
NPI:1811216393
Name:GROSS, EUGENE M (MFC 24448)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:M
Last Name:GROSS
Suffix:
Gender:M
Credentials:MFC 24448
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5015
Mailing Address - Country:US
Mailing Address - Phone:707-293-8328
Mailing Address - Fax:
Practice Address - Street 1:512 BROWN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5015
Practice Address - Country:US
Practice Address - Phone:707-293-8328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 24448106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist