Healthcare Provider Details

I. General information

NPI: 1366726515
Provider Name (Legal Business Name): KIRSTIN GROS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST RALPH H JOHNSON VAMC, MENTAL HEALTH SERVICE LINE 116
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

109 BEE ST RALPH H JOHNSON VAMC, MENTAL HEALTH SERVICE LINE 116
CHARLESTON SC
29401-5703
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone: 843-577-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: