Provider Demographics
NPI:1326772567
Name:ROSS, ANDRE (CT)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 LAKEWOOD AVE LOWR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4924
Mailing Address - Country:US
Mailing Address - Phone:805-791-1836
Mailing Address - Fax:
Practice Address - Street 1:3622 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2704
Practice Address - Country:US
Practice Address - Phone:216-431-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800944101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor