Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant |
NPI | 1013489525 |
---|---|
Provider Name | Mr. Jeremy Alan Gross |
First Address | Valley Grove, WV 26060-8093 |
Second Address | Valley Grove, WV 26060-8093 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2018 |
Last Update Date | 21/12/2018 |