Provider Demographics
NPI:1942424254
Name:ROSS, IRIS FAE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:FAE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 4 BOX 4264
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957
Mailing Address - Country:US
Mailing Address - Phone:573-856-4991
Mailing Address - Fax:573-663-3431
Practice Address - Street 1:110 N. SECOND ST.
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638
Practice Address - Country:US
Practice Address - Phone:573-663-2988
Practice Address - Fax:573-663-3431
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001830101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor