Provider Demographics
NPI:1942320585
Name:GROSSMAN, ELISSA JO (DC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:JO
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1189
Mailing Address - Country:US
Mailing Address - Phone:312-225-9500
Mailing Address - Fax:312-255-9506
Practice Address - Street 1:407 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1189
Practice Address - Country:US
Practice Address - Phone:312-225-9500
Practice Address - Fax:312-255-9506
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007389111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition