Provider Demographics
NPI:1043261951
Name:ROSS, STEPHANIE ANNE (PH D)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANNE
Last Name:ROSS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:ANNE
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3633 W LAKE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-5805
Mailing Address - Country:US
Mailing Address - Phone:773-459-6759
Mailing Address - Fax:773-728-8719
Practice Address - Street 1:1000 CENTRAL ST
Practice Address - Street 2:SUITE 800
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1777
Practice Address - Country:US
Practice Address - Phone:773-459-6756
Practice Address - Fax:773-728-8719
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635161OtherBCBS ID NUMBER
ILK22008Medicare PIN
IL212476Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
P54739Medicare UPIN