Provider Demographics
NPI:1720176951
Name:GROSSMAN, GAGE DENNIS (MSPT)
Entity Type:Individual
Prefix:
First Name:GAGE
Middle Name:DENNIS
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 W LEWIS ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5561
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-544-0304
Practice Address - Street 1:1300 E GRANT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-9485
Practice Address - Country:US
Practice Address - Phone:541-258-8222
Practice Address - Fax:541-258-8221
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2058225100000X
OR5471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR138558Medicare PIN