Provider Demographics
NPI:1598246175
Name:ROSS, JOHN EDWARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:ROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 DEBRA CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2045
Mailing Address - Country:US
Mailing Address - Phone:586-292-1953
Mailing Address - Fax:
Practice Address - Street 1:127 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:810-750-1150
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical