Basic Information
| Provider Information | |||||||||
| NPI: | 1649330796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROS | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4615 GOVERNMENT ST BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708065820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259220474 | ||||||||
| FaxNumber: | 2259220771 | ||||||||
| Practice Location | |||||||||
| Address1: | 4615 GOVERNMENT ST BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708065820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259222656 | ||||||||
| FaxNumber: | 2259220068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 08/31/2009 | ||||||||
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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 | 103TC1900X | 748 | LA | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 1542733 | 05 | LA | MEDICAID |