Healthcare Provider Details

I. General information

NPI: 1952695785
Provider Name (Legal Business Name): DEBRA LYNN GROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14255 SW BRIGADOON CT
BEAVERTON OR
97005-3369
US

IV. Provider business mailing address

14600 NW CORNELL RD
PORTLAND OR
97229-5442
US

V. Phone/Fax

Practice location:
  • Phone: 503-641-1475
  • Fax: 503-641-8548
Mailing address:
  • Phone: 503-645-3581
  • Fax: 503-690-9605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: