Healthcare Provider Details

I. General information

NPI: 1811292998
Provider Name (Legal Business Name): CAROL J GROSS BCBA, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2978 E LOOKOUT DR
EAGLE MOUNTAIN UT
84005-6057
US

IV. Provider business mailing address

2978 E LOOKOUT DR
EAGLE MOUNTAIN UT
84005-6057
US

V. Phone/Fax

Practice location:
  • Phone: 801-920-8949
  • Fax:
Mailing address:
  • Phone: 801-920-8949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5633817-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5651
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: