Basic Information
| Provider Information | |||||||||
| NPI: | 1073841193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAY | ||||||||
| OtherFirstName: | JANICE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CASAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528408 | ||||||||
| FaxNumber: | 5183996860 | ||||||||
| Practice Location | |||||||||
| Address1: | 556 CLINTON AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146201105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854428422 | ||||||||
| FaxNumber: | 5854428494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01420800 | 05 | NY | MEDICAID |