MEDICARE: DANIELLE MARIE GROSS MFT

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	43217	CA

General Provider Information

NPI Number	:	1447340526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE MARIE GROSS MFT

Provider Business Mailing Address
First Line	:	555 N PERRIS BLVD
Second Line	:	BUILDING A
City	:	PERRIS
State	:	CA
Zip	:	92571-2811
Country	:	US
Telephone Number	:	951-436-5309
Fax Number	:	951-436-5350

Provider Business Practice Location Address
First Line	:	555 N PERRIS BLVD
Second Line	:	BUILDING A
City	:	PERRIS
State	:	CA
Zip	:	92571-2811
Country	:	US
Telephone Number	:	951-436-5309
Fax Number	:	951-436-5350

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	12/13/2010

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