Provider Demographics
NPI:1790598506
Name:BOUSHEHRY, ROSS BASTANI
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:BASTANI
Last Name:BOUSHEHRY
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 1:6429 BASTANI PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8614
Mailing Address - Country:US
Mailing Address - Phone:317-490-2000
Mailing Address - Fax:
Practice Address - Street 1:6429 BASTANI PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8614
Practice Address - Country:US
Practice Address - Phone:317-490-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3004486A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker