Provider Demographics
NPI:1811905250
Name:ROSS, LAWRENCE M (PHD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:ROSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4164 VIRGINIA BEACH BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1762
Mailing Address - Country:US
Mailing Address - Phone:757-623-2228
Mailing Address - Fax:757-623-7186
Practice Address - Street 1:4164 VIRGINIA BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1762
Practice Address - Country:US
Practice Address - Phone:757-623-2228
Practice Address - Fax:757-623-7186
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7728476Medicaid
VA7728476Medicaid