Provider Demographics
NPI:1144797531
Name:ROSS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2761
Mailing Address - Country:US
Mailing Address - Phone:662-371-1711
Mailing Address - Fax:844-512-2577
Practice Address - Street 1:202 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2761
Practice Address - Country:US
Practice Address - Phone:662-371-1711
Practice Address - Fax:844-512-2577
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional