Basic Information
| Provider Information | |||||||||
| NPI: | 1407101207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3915 N 54TH WAY | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850184537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129137839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 E MISSOURI AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023930520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4648 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.