Provider Demographics
NPI:1619755410
Name:HEALEA, ROSS JOHN (RBT)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:JOHN
Last Name:HEALEA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 ANTHONY DR APT A
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-6856
Mailing Address - Country:US
Mailing Address - Phone:618-420-1243
Mailing Address - Fax:
Practice Address - Street 1:411 EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1339
Practice Address - Country:US
Practice Address - Phone:314-275-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-21-192923106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician