Provider Demographics
NPI:1033845623
Name:ROSS, CARLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:ROSS
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 1:118 E 3RD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1257
Mailing Address - Country:US
Mailing Address - Phone:989-619-1077
Mailing Address - Fax:
Practice Address - Street 1:1070 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9613
Practice Address - Country:US
Practice Address - Phone:989-619-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty