Provider Demographics
NPI:1669798658
Name:GROSS, CRAIG VIKING
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:VIKING
Last Name:GROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4465
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-8465
Mailing Address - Country:US
Mailing Address - Phone:303-875-5869
Mailing Address - Fax:
Practice Address - Street 1:615 CHIMBORAZO BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7530
Practice Address - Country:US
Practice Address - Phone:303-875-5869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0157485415Medicaid