Provider Demographics
NPI:1083834246
Name:WILLIAM L ROSS
Entity Type:Organization
Organization Name:WILLIAM L ROSS
Other - Org Name:AMELIA PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-277-2052
Mailing Address - Street 1:1405 PARK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1950
Mailing Address - Country:US
Mailing Address - Phone:904-277-2052
Mailing Address - Fax:904-277-2083
Practice Address - Street 1:1405 PARK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1950
Practice Address - Country:US
Practice Address - Phone:904-277-2052
Practice Address - Fax:904-277-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6579101YM0800X
FLPY4456103T00000X
FLPY2557103T00000X, 106H00000X
FLSW69131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3074Medicare ID - Type UnspecifiedGROUP NUMBER
FLU0526Medicare ID - Type Unspecified
FL54601AMedicare ID - Type Unspecified
FL75666AMedicare ID - Type Unspecified