Provider Demographics
NPI:1053620872
Name:GROSS, CARMELINE F
Entity type:Individual
Prefix:
First Name:CARMELINE
Middle Name:F
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WINTHROP LN
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-8025
Mailing Address - Country:US
Mailing Address - Phone:386-569-3998
Mailing Address - Fax:386-569-3998
Practice Address - Street 1:12 WINTHROP LN
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-8025
Practice Address - Country:US
Practice Address - Phone:386-569-3998
Practice Address - Fax:386-693-3214
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 3622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist