Healthcare Provider Details

I. General information

NPI: 1194951152
Provider Name (Legal Business Name): ROSS RODGERS WILLIAMS MFT TRAINEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 VAN NUYS BLVD STE 200
PACOIMA CA
91331-1393
US

IV. Provider business mailing address

12450 VAN NUYS BLVD STE 200
PACOIMA CA
91331-1393
US

V. Phone/Fax

Practice location:
  • Phone: 188-961-1618
  • Fax: 818-896-5069
Mailing address:
  • Phone: 188-961-1618
  • Fax: 818-896-5069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: