Provider Demographics
NPI:1568510097
Name:ROSS, LARRY EDWIN (LPC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EDWIN
Last Name:ROSS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5177
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85010-5177
Mailing Address - Country:US
Mailing Address - Phone:602-344-5651
Mailing Address - Fax:602-344-5578
Practice Address - Street 1:1144 E MCDOWELL RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2664
Practice Address - Country:US
Practice Address - Phone:602-344-5651
Practice Address - Fax:602-344-5578
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1753101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ704983Medicaid