Provider Demographics
NPI:1801953658
Name:GROSS, EDWARD (PHD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 47 14TH STREET
Mailing Address - Street 2:APT 6A
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106
Mailing Address - Country:US
Mailing Address - Phone:718-956-4133
Mailing Address - Fax:718-956-4133
Practice Address - Street 1:333 WEST 57TH STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-265-2161
Practice Address - Fax:718-956-4133
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY5624103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01272224Medicaid
P853351OtherOXFORD HEALTH PLANS
NY01272224Medicaid