Provider Demographics
NPI:1952817207
Name:ROSS, EBONE (MPA, QMHP)
Entity Type:Individual
Prefix:
First Name:EBONE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MPA, QMHP
Other - Prefix:
Other - First Name:EBONE
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1660
Mailing Address - Country:US
Mailing Address - Phone:618-658-2611
Mailing Address - Fax:
Practice Address - Street 1:101 OLIVER ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1660
Practice Address - Country:US
Practice Address - Phone:618-658-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health