Healthcare Provider Details

I. General information

NPI: 1023029832
Provider Name (Legal Business Name): ANGELA M. ROSS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W CLAY RD
VERSAILLES MO
65084
US

IV. Provider business mailing address

821 WESTWOOD DR
SEDALIA MO
65301-2102
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-2349
  • Fax: 888-979-8868
Mailing address:
  • Phone: 660-826-4774
  • Fax: 660-827-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-009253
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2016030115
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: