Basic Information
Provider Information | |||||||||
NPI: | 1457864258 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | KATHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CDCA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 323 MARION PIKE STE 3 | ||||||||
Address2: |   | ||||||||
City: | COAL GROVE | ||||||||
State: | OH | ||||||||
PostalCode: | 456382958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7406466640 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 323 MARION PIKE STE 3 | ||||||||
Address2: |   | ||||||||
City: | COAL GROVE | ||||||||
State: | OH | ||||||||
PostalCode: | 45638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7406466640 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2017 | ||||||||
LastUpdateDate: | 08/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 11/20/2017 | ||||||||
NPIReactivationDate: | 08/13/2019 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.130948 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | CDCA.130948 | 01 | OH | OHIO CHEMICAL DEPENDECY PROFESSIONALS BOARD | OTHER |