Provider Demographics
NPI:1336312263
Name:ROSS, TRACY M (MDIV)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53224
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46253-0224
Mailing Address - Country:US
Mailing Address - Phone:317-664-1390
Mailing Address - Fax:
Practice Address - Street 1:4218 GUION LAKES TER
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1594
Practice Address - Country:US
Practice Address - Phone:317-664-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201034050AMedicaid