MEDICARE: KELSEY GROSS- CRAIG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1104646082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY GROSS- CRAIG

Provider Business Mailing Address
First Line	:	3535 MOUNTAIN CREEK RD APT 402
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6715
Country	:	US
Telephone Number	:	303-656-3707
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 MOUNTAIN CREEK RD APT 402
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6715
Country	:	US
Telephone Number	:	303-656-3707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2024
Last Update Date	:	10/15/2024

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