Provider Demographics
NPI:1083786503
Name:ROSS, GINA (MFC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 SOUTH LORRAINE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3811
Mailing Address - Country:US
Mailing Address - Phone:323-930-2151
Mailing Address - Fax:323-935-8417
Practice Address - Street 1:269 LORRAINE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3811
Practice Address - Country:US
Practice Address - Phone:323-930-2151
Practice Address - Fax:323-935-8417
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22453106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist