Provider Demographics
NPI:1497085757
Name:ROSS, MICKI LINDA (LCSW)
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:LINDA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LINDA DARLENE
Other - Middle Name:MICKI
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27559 PASEO SEGOVIA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-5367
Mailing Address - Country:US
Mailing Address - Phone:949-291-0936
Mailing Address - Fax:949-388-4507
Practice Address - Street 1:27559 PASEO SEGOVIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-291-0936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-10
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical