Provider Demographics
NPI:1205139425
Name:ROSS, KELLY RAY (TLMSW)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:RAY
Last Name:ROSS
Suffix:
Gender:M
Credentials:TLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 MARTWAY CIR APT B
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-5820
Mailing Address - Country:US
Mailing Address - Phone:785-766-7898
Mailing Address - Fax:
Practice Address - Street 1:1125 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-3123
Practice Address - Country:US
Practice Address - Phone:913-713-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7950103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst