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NPI Code Detail

MEDICARE: GEORGIA KELLY GROSS BS, RBT

MEDICARE: GEORGIA KELLY GROSS BS, RBT
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
1106S00000XBehavior TechnicianRBT-19-99351IN

General Provider Information

NPI Number : 1275130361
Entity Type Code : Individual
Provider Name (Legal Business Name) : GEORGIA KELLY GROSS BS, RBT
Provider Business Mailing Address
First Line : 11922 FAIRWAY LAKES DR STE 2
Second Line :
City : FORT MYERS
State : FL
Zip : 33913-8384
Country : US
Telephone Number : 239-219-3409
Fax Number :
Provider Business Practice Location Address
First Line : 11922 FAIRWAY LAKES DR STE 2
Second Line :
City : FORT MYERS
State : FL
Zip : 33913-8384
Country : US
Telephone Number : 239-219-3409
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/02/2020
Last Update Date : 11/29/2022

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