Provider Demographics
NPI:1053336511
Name:GROSS, AMY (PHD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NOGALES DR
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-5117
Mailing Address - Country:US
Mailing Address - Phone:818-705-5639
Mailing Address - Fax:
Practice Address - Street 1:22622 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2646
Practice Address - Country:US
Practice Address - Phone:919-464-3333
Practice Address - Fax:818-464-3249
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY11189OtherPSYCHOLOGIST LICENSE