Basic Information
| Provider Information | |||||||||
| NPI: | 1861773749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | NORA | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 CHURCH HILL RD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | LEEDS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042633418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075243501 | ||||||||
| FaxNumber: | 2075242093 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040091167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075243501 | ||||||||
| FaxNumber: | 2076474000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2011 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC13174 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LC14510 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1861773749 | 05 | ME | MEDICAID |