Provider Demographics
NPI:1821059627
Name:GROSS, ELEANOR (LCSW)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WILD DUNES WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4040
Mailing Address - Country:US
Mailing Address - Phone:732-928-0078
Mailing Address - Fax:732-928-0078
Practice Address - Street 1:95 WILD DUNES WAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-4040
Practice Address - Country:US
Practice Address - Phone:732-928-0078
Practice Address - Fax:732-928-0078
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC006003001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJR33975Medicare UPIN
NJ646645TB1Medicare ID - Type Unspecified