Provider Demographics
NPI:1497849079
Name:ROSS, PHYLLIS (LICSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 GORDON ROAD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468
Mailing Address - Country:US
Mailing Address - Phone:617-285-8639
Mailing Address - Fax:781-721-2113
Practice Address - Street 1:573 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890
Practice Address - Country:US
Practice Address - Phone:782-729-4010
Practice Address - Fax:781-721-2113
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105628101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health