Provider Demographics
NPI:1639691066
Name:ROSS, SUSAN C (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
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 1:7229 FOREST AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3765
Mailing Address - Country:US
Mailing Address - Phone:804-281-0275
Mailing Address - Fax:804-521-9344
Practice Address - Street 1:5855 BREMO RD STE 403
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1924
Practice Address - Country:US
Practice Address - Phone:804-288-2673
Practice Address - Fax:804-285-5572
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040093101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06778OtherMEEDICARE GROUP PTAN