Healthcare Provider Details

I. General information

NPI: 1043603590
Provider Name (Legal Business Name): ELIZABETH GROSS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HORTON FIELDHOUSE CAMPUS BOX 7130
NORMAL IL
61790-0001
US

IV. Provider business mailing address

2000 N LINDEN ST APT H308
NORMAL IL
61761-5321
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-7246
  • Fax:
Mailing address:
  • Phone: 715-579-7194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: