Provider Demographics
NPI:1649679804
Name:GROSS, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 5TH ST NW UNIT 790
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7118
Mailing Address - Country:US
Mailing Address - Phone:701-444-3661
Mailing Address - Fax:701-444-6436
Practice Address - Street 1:201 5TH ST NW UNIT 790
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7118
Practice Address - Country:US
Practice Address - Phone:701-444-3661
Practice Address - Fax:701-444-6436
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4974104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker