Provider Demographics
NPI:1114192382
Name:ROSS, DARLENE (BS, MS AND (CSAC) 14)
Entity Type:Individual
Prefix:MS
First Name:DARLENE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:BS, MS AND (CSAC) 14
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 N 58TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4251
Mailing Address - Country:US
Mailing Address - Phone:414-364-7695
Mailing Address - Fax:414-810-3706
Practice Address - Street 1:5103 N 58TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4251
Practice Address - Country:US
Practice Address - Phone:414-810-3706
Practice Address - Fax:414-810-3702
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41161300Medicaid