Basic Information
| Provider Information | |||||||||
| NPI: | 1649939323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | PRESTON | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4814 COLE BLVD | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481973718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1269932590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 N 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481045503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6852093123 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.