Healthcare Provider Details

I. General information

NPI: 1417321563
Provider Name (Legal Business Name): KELLIE MICHELLE ROSS LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 RAMSEY ST
FAYETTEVILLE NC
28301-4909
US

IV. Provider business mailing address

3125 POPLARWOOD CT STE 203
RALEIGH NC
27604-6445
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-6131
  • Fax:
Mailing address:
  • Phone: 919-787-6131
  • Fax: 919-571-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-21914
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCAS-21914
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: