Provider Demographics
NPI:1467917377
Name:ROSS, LAURA BETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:BETH
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:BETH
Other - Last Name:FULTONBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5161 W RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1990
Mailing Address - Country:US
Mailing Address - Phone:443-858-5507
Mailing Address - Fax:
Practice Address - Street 1:6601 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5700
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-174221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical