Provider Demographics
NPI:1255778106
Name:ROSS, EMILY M (CACI)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 WISE RD
Mailing Address - Street 2:P. O. BOX 136
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5521
Mailing Address - Country:US
Mailing Address - Phone:843-365-8884
Mailing Address - Fax:843-365-6685
Practice Address - Street 1:2404 WISE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5521
Practice Address - Country:US
Practice Address - Phone:843-365-8884
Practice Address - Fax:843-365-6685
Is Sole Proprietor?:No
Enumeration Date:2013-06-02
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)