Basic Information
| Provider Information | |||||||||
| NPI: | 1922667625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | BRIANNA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LCGC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 ARCH ST UNIT 301 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326739363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901719 | ||||||||
| FaxNumber: | 2155901771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2019 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | G000468 | PA | Y | Other Service Providers | Genetic Counselor, MS |
No ID Information.