Provider Demographics
NPI:1639388242
Name:ROSS, TAMIKA (ST)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 TRINITY LN
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1296
Mailing Address - Country:US
Mailing Address - Phone:601-502-6222
Mailing Address - Fax:
Practice Address - Street 1:707 TRINITY LN
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1296
Practice Address - Country:US
Practice Address - Phone:601-502-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2907225500000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4250496048AOtherBCBS GROUP
MS01901799Medicaid