Basic Information
| Provider Information | |||||||||
| NPI: | 1639105430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | BART | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16531 BOLSA CHICA ST | ||||||||
| Address2: | STE 314 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926493596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237911808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16531 BOLSA CHICA ST | ||||||||
| Address2: | STE 314 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926493596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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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 | PSY15175 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00CP151750 | 05 | CA | MEDICAID |