Provider Demographics
NPI:1396907333
Name:RICHARD S. GROSS, PH.D,,PC
Entity type:Organization
Organization Name:RICHARD S. GROSS, PH.D,,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-520-9776
Mailing Address - Street 1:3301 BALMORAL DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5617
Mailing Address - Country:US
Mailing Address - Phone:770-939-5341
Mailing Address - Fax:770-939-5341
Practice Address - Street 1:2711 IRVIN WAY
Practice Address - Street 2:SUITE 211
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-5405
Practice Address - Country:US
Practice Address - Phone:404-530-9776
Practice Address - Fax:770-939-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000371103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCDFMedicare PIN