Provider Demographics
NPI:1902687601
Name:GROSS, SHIRI NICOLE
Entity Type:Individual
Prefix:
First Name:SHIRI
Middle Name:NICOLE
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 W JACKSON BLVD STE 1632
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3734
Mailing Address - Country:US
Mailing Address - Phone:312-725-8685
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 1632
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3734
Practice Address - Country:US
Practice Address - Phone:312-725-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111836104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker