Healthcare Provider Details

I. General information

NPI: 1093680134
Provider Name (Legal Business Name): AIESHA ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

IV. Provider business mailing address

706 RHODES ST
LAKE CHARLES LA
70601-4783
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-0324
  • Fax: 337-475-8917
Mailing address:
  • Phone: 337-475-0324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number351919
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: