=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063027647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA DANNIELLE GROSSO MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2020
-----------------------------------------------------
Last Update Date | 09/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 E MAIN ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98002-5662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-931-4880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1126 31ST ST NW
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-521-2742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | LL61078219
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------