Provider Demographics
NPI:1639105430
Name:ROSS, BART LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BART
Middle Name:LEE
Last Name:ROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16531 BOLSA CHICA ST
Mailing Address - Street 2:STE 314
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3596
Mailing Address - Country:US
Mailing Address - Phone:323-791-1808
Mailing Address - Fax:
Practice Address - Street 1:16531 BOLSA CHICA ST
Practice Address - Street 2:STE 314
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3596
Practice Address - Country:US
Practice Address - Phone:626-963-4467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15175103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00CP151750Medicaid
CACP15175Medicare ID - Type Unspecified