=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902470925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE MICHELLE GROSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2021
-----------------------------------------------------
Last Update Date | 05/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 BEACH 20TH ST
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-327-7002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2703 BAYVIEW AVE
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-578-5263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------