Provider Demographics
NPI:1821322314
Name:ROSS, KELLY B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:B
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 1:6268 SPRING XING
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5812
Mailing Address - Country:US
Mailing Address - Phone:901-270-3542
Mailing Address - Fax:815-377-3622
Practice Address - Street 1:5900 GOODMAN RD.
Practice Address - Street 2:SUITE B
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:901-270-3542
Practice Address - Fax:815-377-3622
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC56891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical