Healthcare Provider Details

I. General information

NPI: 1437528072
Provider Name (Legal Business Name): VICKI L GROSS MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 SILVER PALM DR
EDGEWATER FL
32141-5501
US

IV. Provider business mailing address

2809 SILVER PALM DR
EDGEWATER FL
32141-5501
US

V. Phone/Fax

Practice location:
  • Phone: 386-427-9081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: