Provider Demographics
NPI:1821023797
Name:GROSS, DENISE K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:K
Last Name:GROSS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 111TH ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9468
Mailing Address - Country:US
Mailing Address - Phone:941-756-0292
Mailing Address - Fax:941-756-0161
Practice Address - Street 1:6015 111TH ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9468
Practice Address - Country:US
Practice Address - Phone:941-756-0292
Practice Address - Fax:941-756-0161
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004484103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL211652900Medicaid
FL211652900Medicaid