1497085757 NPI number — MICKI LINDA ROSS LCSW

Table of content: MICKI LINDA ROSS LCSW (NPI 1497085757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497085757 NPI number — MICKI LINDA ROSS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
MICKI
Provider Middle Name:
LINDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORRIS
Provider Other First Name:
LINDA DARLENE
Provider Other Middle Name:
MICKI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497085757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27559 PASEO SEGOVIA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN CAPISTRANO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92675-5367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-291-0936
Provider Business Mailing Address Fax Number:
949-388-4507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27559 PASEO SEGOVIA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN CAPISTRANO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-291-0936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  26059 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)