Basic Information
| Provider Information | |||||||||
| NPI: | 1407575723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MACY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2669 WELLESLEY DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492019318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173926578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2022 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | R200570210873 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.