Provider Demographics
NPI:1417321563
Name:ROSS, KELLIE MICHELLE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MICHELLE
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 1:6819 KIZER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5427
Mailing Address - Country:US
Mailing Address - Phone:252-290-2685
Mailing Address - Fax:
Practice Address - Street 1:6819 KIZER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5427
Practice Address - Country:US
Practice Address - Phone:252-290-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-A-21914101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)