Provider Demographics
NPI:1801124987
Name:D'ROSS, LYDIA MARIA (CMII)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIA
Last Name:D'ROSS
Suffix:
Gender:F
Credentials:CMII
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MARIA
Other - Last Name:GONZALEZ-D'ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BHCM- CHAPLAIN
Mailing Address - Street 1:PO BOX 702622
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2622
Mailing Address - Country:US
Mailing Address - Phone:918-430-8350
Mailing Address - Fax:
Practice Address - Street 1:7742 SOUTH VICTOR AVENUE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74173
Practice Address - Country:US
Practice Address - Phone:918-430-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9315171M00000X
171W00000X, 251B00000X, 251S00000X
OK2011013009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health