Provider Demographics
NPI:1083176127
Name:ROSS, MARK GRIFF (LCDC III 141287)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GRIFF
Last Name:ROSS
Suffix:
Gender:M
Credentials:LCDC III 141287
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1161 CRESTVIEW ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1365
Mailing Address - Country:US
Mailing Address - Phone:614-893-3113
Mailing Address - Fax:
Practice Address - Street 1:5460 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-4005
Practice Address - Country:US
Practice Address - Phone:614-568-8236
Practice Address - Fax:614-271-3175
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141287101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)