Provider Demographics
NPI:1376895359
Name:ROSS, MALISHA LULAIDA (LCAS-A)
Entity Type:Individual
Prefix:
First Name:MALISHA
Middle Name:LULAIDA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5212 GRASS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2970
Mailing Address - Country:US
Mailing Address - Phone:704-430-4250
Mailing Address - Fax:704-853-8751
Practice Address - Street 1:5212 GRASS RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-2970
Practice Address - Country:US
Practice Address - Phone:704-430-4250
Practice Address - Fax:704-823-8751
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2494-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)