Provider Demographics
NPI:1598821563
Name:ROSS, SUSAN ACKERMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ACKERMAN
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6263 POPLAR AVE
Mailing Address - Street 2:SUITE 932
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4701
Mailing Address - Country:US
Mailing Address - Phone:901-763-2188
Mailing Address - Fax:901-683-5926
Practice Address - Street 1:6263 POPLAR AVE
Practice Address - Street 2:SUITE 932
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4701
Practice Address - Country:US
Practice Address - Phone:901-763-2188
Practice Address - Fax:901-683-5926
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1062103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN398-1818Medicare ID - Type Unspecified