Provider Demographics
NPI:1891842563
Name:ROSS, THERESA L (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:SUITE G11
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-1710
Mailing Address - Fax:208-239-1713
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:SUITE G11
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1710
Practice Address - Fax:208-239-1713
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202084103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807126900Medicaid
ID807126900Medicaid