Provider Demographics
NPI:1750919379
Name:ROSS, MICHAEL ALLEN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
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 1:9013 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-7700
Mailing Address - Country:US
Mailing Address - Phone:304-755-1769
Mailing Address - Fax:855-843-9349
Practice Address - Street 1:9013 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-7700
Practice Address - Country:US
Practice Address - Phone:304-755-1769
Practice Address - Fax:855-843-9349
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker