Provider Demographics
NPI:1922779750
Name:GROSS, CRAIG MATTHEW (LAT, ATC,CPED)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:MATTHEW
Last Name:GROSS
Suffix:
Gender:M
Credentials:LAT, ATC,CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-9281
Mailing Address - Country:US
Mailing Address - Phone:812-457-6243
Mailing Address - Fax:
Practice Address - Street 1:415 CROSSLAKE DR STE B
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8272
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001858A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer