Provider Demographics
NPI:1295100881
Name:ROSS, OLIVER (PSYD)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 SELBY AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6285
Mailing Address - Country:US
Mailing Address - Phone:612-206-1259
Mailing Address - Fax:
Practice Address - Street 1:1595 SELBY AVE STE 112
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6285
Practice Address - Country:US
Practice Address - Phone:612-206-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical