Healthcare Provider Details

I. General information

NPI: 1992241871
Provider Name (Legal Business Name): KAITLYN GROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 CAMINO DEL LLANO
BELEN NM
87002-2619
US

IV. Provider business mailing address

1831 CAMINO DEL LLANO
BELEN NM
87002-2619
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1324
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: