Provider Demographics
NPI:1356838940
Name:ROSS, EVELYN L
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:L
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 1:5211 MAHONING AVE STE 370
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1853
Mailing Address - Country:US
Mailing Address - Phone:330-792-4724
Mailing Address - Fax:330-792-1848
Practice Address - Street 1:5211 MAHONING AVE STE 370
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1853
Practice Address - Country:US
Practice Address - Phone:330-792-4724
Practice Address - Fax:330-792-1848
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164427101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)