Provider Demographics
NPI:1265839823
Name:GROSS, BRIAN DANIEL (LMP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DANIEL
Last Name:GROSS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12506 18TH ST NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8145
Mailing Address - Country:US
Mailing Address - Phone:425-334-5409
Mailing Address - Fax:
Practice Address - Street 1:12506 18TH ST NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-8145
Practice Address - Country:US
Practice Address - Phone:425-334-5409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60438589225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist