Provider Demographics
NPI:1891452975
Name:SOUTH-GROSS, MARY ANN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:SOUTH-GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1640
Mailing Address - Country:US
Mailing Address - Phone:618-382-2341
Mailing Address - Fax:618-384-3207
Practice Address - Street 1:205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1485
Practice Address - Country:US
Practice Address - Phone:618-382-4631
Practice Address - Fax:618-384-2076
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist