Provider Demographics
NPI:1831747773
Name:ROSS, JOHN MUNDER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MUNDER
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 1:170 E END AVE APT 2L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-7678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 E END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-7600
Practice Address - Country:US
Practice Address - Phone:917-273-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05123103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Single Specialty