Provider Demographics
NPI:1740812767
Name:GROSS, BRANDON PATRICK (LLMSW)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:PATRICK
Last Name:GROSS
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CHAMPION ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4921
Mailing Address - Country:US
Mailing Address - Phone:906-360-3617
Mailing Address - Fax:
Practice Address - Street 1:102 W WASHINGTON ST STE 106
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4350
Practice Address - Country:US
Practice Address - Phone:906-228-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801106497104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker