Provider Demographics
NPI:1356669881
Name:ROSS, KEISHA SUENELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEISHA
Middle Name:SUENELLE
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 HIGHWAY N
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7013
Mailing Address - Country:US
Mailing Address - Phone:636-561-7080
Mailing Address - Fax:
Practice Address - Street 1:7400 HIGHWAY N
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7013
Practice Address - Country:US
Practice Address - Phone:636-561-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1851459473Medicaid