Provider Demographics
NPI:1912655630
Name:ROSS, RACQUEL SIMONE
Entity Type:Individual
Prefix:
First Name:RACQUEL
Middle Name:SIMONE
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 OAKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1744
Mailing Address - Country:US
Mailing Address - Phone:541-852-5648
Mailing Address - Fax:
Practice Address - Street 1:3261 OAKSHIRE DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1744
Practice Address - Country:US
Practice Address - Phone:541-852-5648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131084106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist