Provider Demographics
NPI:1003132473
Name:ROSS, TONYETTA L (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:TONYETTA
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W CLAYTON CREST AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3830
Mailing Address - Country:US
Mailing Address - Phone:414-690-0672
Mailing Address - Fax:
Practice Address - Street 1:5330 W VILLARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4345
Practice Address - Country:US
Practice Address - Phone:414-488-6291
Practice Address - Fax:414-488-6293
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-10
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16074-132101Y00000X
101YA0400X, 101YM0800X, 171M00000X, 101YP2500X
WI7597-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12088599OtherCAQH