=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245240183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA L GROSS PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 08/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16055 VENTURA BLVD SUITE 500
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-334-5576
-----------------------------------------------------
Fax | 818-912-6353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21555 BURBANK BLVD. #41
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-358-7996
-----------------------------------------------------
Fax | 818-912-6353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY 9774
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 9774
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------