Provider Demographics
NPI:1457421737
Name:ROSS, DESIREE KENYETTA (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:DESIREE
Middle Name:KENYETTA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 SAGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-2234
Mailing Address - Country:US
Mailing Address - Phone:718-757-0643
Mailing Address - Fax:
Practice Address - Street 1:89 SAGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-2234
Practice Address - Country:US
Practice Address - Phone:718-757-0643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PACW0162071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health