Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 217349 | MA |
NPI | 1003247305 |
---|---|
Provider Name | Ivy B Gross |
First Address | Somerville, MA 02145-2908 |
Second Address | Lunenburg, MA 01462-2013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2013 |
Last Update Date | 28/09/2015 |