Healthcare Provider Details

I. General information

NPI: 1336312263
Provider Name (Legal Business Name): TRACY M ROSS M.DIV.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 GUION LAKES TER
INDIANAPOLIS IN
46254-1594
US

IV. Provider business mailing address

PO BOX 53224
INDIANAPOLIS IN
46253-0224
US

V. Phone/Fax

Practice location:
  • Phone: 317-664-1390
  • Fax:
Mailing address:
  • Phone: 317-664-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: