Provider Demographics
NPI:1245105949
Name:ROSS, SPENCER IAN
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:IAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 CENTRAL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-3684
Mailing Address - Country:US
Mailing Address - Phone:707-630-4000
Mailing Address - Fax:
Practice Address - Street 1:2355 CENTRAL AVE STE D
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3684
Practice Address - Country:US
Practice Address - Phone:707-630-4000
Practice Address - Fax:707-630-4000
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty