Healthcare Provider Details

I. General information

NPI: 1770620593
Provider Name (Legal Business Name): KRISTIN GROSS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 OXFORD ST
BERKELEY CA
94709-1422
US

IV. Provider business mailing address

1215 OXFORD ST
BERKELEY CA
94709-1422
US

V. Phone/Fax

Practice location:
  • Phone: 510-530-1676
  • Fax:
Mailing address:
  • Phone: 510-530-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number19304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: