Provider Demographics
NPI:1346598638
Name:ROSS, DUSTIN (MA, EDS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1103
Mailing Address - Country:US
Mailing Address - Phone:718-436-7979
Mailing Address - Fax:
Practice Address - Street 1:160 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1103
Practice Address - Country:US
Practice Address - Phone:718-436-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool