Provider Demographics
NPI:1356682629
Name:ROSS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7218 CRESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-7022
Mailing Address - Country:US
Mailing Address - Phone:404-543-9701
Mailing Address - Fax:
Practice Address - Street 1:7218 CRESTSIDE DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-7022
Practice Address - Country:US
Practice Address - Phone:404-543-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child