Provider Demographics
NPI:1922527860
Name:GROSS, ANITA JO (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:JO
Last Name:GROSS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3871
Mailing Address - Country:US
Mailing Address - Phone:618-542-2646
Mailing Address - Fax:618-542-6291
Practice Address - Street 1:845 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3871
Practice Address - Country:US
Practice Address - Phone:618-542-2646
Practice Address - Fax:618-542-6291
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist