Provider Demographics
NPI:1235325309
Name:ROSS, KATHLEEN M (LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-4360
Mailing Address - Fax:
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3898-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43724700Medicaid