Provider Demographics
NPI:1265678148
Name:ROSS, MIRIAM LOUISE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:LOUISE
Last Name:ROSS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:MIMI
Other - Middle Name:LOUISE
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:15 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1915
Mailing Address - Country:US
Mailing Address - Phone:617-964-3676
Mailing Address - Fax:
Practice Address - Street 1:15 VINCENT ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-1915
Practice Address - Country:US
Practice Address - Phone:617-964-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-26
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1009961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical