Provider Demographics
NPI:1609360908
Name:ROSS, MISTY DAWN RAY (LCSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN RAY
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 N ARMENIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1661
Mailing Address - Country:US
Mailing Address - Phone:813-490-5490
Mailing Address - Fax:813-490-5495
Practice Address - Street 1:2902 N ARMENIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-490-5490
Practice Address - Fax:813-490-5495
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW147601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW14760OtherLCSW