Provider Demographics
NPI:1346378361
Name:ROSS, IMAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:IMAN
Middle Name:J
Last Name:ROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 SANTA FE TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-3063
Mailing Address - Country:US
Mailing Address - Phone:469-236-3999
Mailing Address - Fax:469-293-4144
Practice Address - Street 1:1106 SANTA FE TRL STE 2
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3063
Practice Address - Country:US
Practice Address - Phone:469-236-3999
Practice Address - Fax:469-293-4144
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18030101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional