Provider Demographics
NPI:1457864258
Name:ROSS, KATHY (CDCA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MARION PIKE STE 3
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2958
Mailing Address - Country:US
Mailing Address - Phone:740-646-6640
Mailing Address - Fax:
Practice Address - Street 1:323 MARION PIKE STE 3
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2019-08-28
Deactivation Date:2017-11-20
Deactivation Code:
Reactivation Date:2019-08-13
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.130948101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.130948OtherOHIO CHEMICAL DEPENDECY PROFESSIONALS BOARD