Provider Demographics
NPI:1487082921
Name:POLESE-GROSSO, GINA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:ANN
Last Name:POLESE-GROSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BRISCOE DR
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3140
Mailing Address - Country:US
Mailing Address - Phone:732-458-1700
Mailing Address - Fax:
Practice Address - Street 1:1500 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2320
Practice Address - Country:US
Practice Address - Phone:732-458-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC001991001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical