Provider Demographics
NPI:1467458695
Name:ROSS, STEPHEN GERARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GERARD
Last Name:ROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 W JEFFERSON BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6800
Mailing Address - Country:US
Mailing Address - Phone:260-436-4100
Mailing Address - Fax:260-432-6282
Practice Address - Street 1:4630 W JEFFERSON BLVD STE 5
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6800
Practice Address - Country:US
Practice Address - Phone:260-436-4100
Practice Address - Fax:260-432-6282
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-04-14
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
IN20040536A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN185800AMedicare PIN
INR99231Medicare UPIN