Provider Demographics
NPI:1467754697
Name:ROSS, TINESELLA RAYNETTE (MSW, PLCSW, PLCAS)
Entity Type:Individual
Prefix:MRS
First Name:TINESELLA
Middle Name:RAYNETTE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MSW, PLCSW, PLCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2140
Mailing Address - Country:US
Mailing Address - Phone:704-861-8014
Mailing Address - Fax:704-854-4860
Practice Address - Street 1:2505 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-861-8014
Practice Address - Fax:704-854-4860
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301469Medicaid
NC6005727Medicaid