Basic Information
| Provider Information | |||||||||
| NPI: | 1386737146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | DIXON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 ALDEN DRIVE | ||||||||
| Address2: | ATTN: 90MDOS/SGOF - FAM HLTH | ||||||||
| City: | FE WARREN AFB | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820053913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077733230 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 ALDEN DRIVE | ||||||||
| Address2: | ATTN: 90 MDOS/SGOF-FAM HLTH | ||||||||
| City: | FE WARREN AFB | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820053913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077733230 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2542 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 55807828 | 05 | CO | MEDICAID |