Provider Demographics
NPI:1952063554
Name:ROSS, KELLY (LPCC 9953)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LPCC 9953
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26417 LARKSPUR ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-6410
Mailing Address - Country:US
Mailing Address - Phone:951-491-1797
Mailing Address - Fax:
Practice Address - Street 1:41680 IVY ST STE D
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9435
Practice Address - Country:US
Practice Address - Phone:619-549-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional