Provider Demographics
NPI:1760516660
Name:STEPHANIE A ROSS LICENSED CLINICAL PSYCHOLOGIST PC
Entity Type:Organization
Organization Name:STEPHANIE A ROSS LICENSED CLINICAL PSYCHOLOGIST PC
Other - Org Name:STEPHANIE A ROSS LICENSED CLINICAL PSYCHOLOGIST PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNED
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-459-6756
Mailing Address - Street 1:3633 W LAKE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-5805
Mailing Address - Country:US
Mailing Address - Phone:773-459-6756
Mailing Address - Fax:773-728-8719
Practice Address - Street 1:3633 W LAKE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5805
Practice Address - Country:US
Practice Address - Phone:773-459-6756
Practice Address - Fax:773-728-8719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX