Provider Demographics
NPI:1265705529
Name:GROSS, SUSAN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BELMONT BAY DR
Mailing Address - Street 2:#406
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5476
Mailing Address - Country:US
Mailing Address - Phone:703-766-8708
Mailing Address - Fax:703-766-8713
Practice Address - Street 1:5632 MOUNT VERNON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-1502
Practice Address - Country:US
Practice Address - Phone:703-766-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst