Healthcare Provider Details

I. General information

NPI: 1699245928
Provider Name (Legal Business Name): MISTY JOHNETTA ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2942 KNIGHT ST. BLDG. 4 SUITE 426
SHREVEPORT LA
71105
US

IV. Provider business mailing address

3555 CEDAR CREEK DR APT 913
SHREVEPORT LA
71118-2349
US

V. Phone/Fax

Practice location:
  • Phone: 318-754-3560
  • Fax:
Mailing address:
  • Phone: 318-564-7436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: