Provider Demographics
NPI:1538851407
Name:GROSS, MATTHEW RYAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:GROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10057 ELKHORN CRK
Mailing Address - Street 2:
Mailing Address - City:ASHCAMP
Mailing Address - State:KY
Mailing Address - Zip Code:41512-8702
Mailing Address - Country:US
Mailing Address - Phone:606-754-7077
Mailing Address - Fax:
Practice Address - Street 1:10057 ELKHORN CRK
Practice Address - Street 2:
Practice Address - City:ASHCAMP
Practice Address - State:KY
Practice Address - Zip Code:41512-8702
Practice Address - Country:US
Practice Address - Phone:606-754-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker