Healthcare Provider Details

I. General information

NPI: 1265606917
Provider Name (Legal Business Name): NINA SUZANNE ROSS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 HANO RD
SANTA FE NM
87505-3307
US

IV. Provider business mailing address

1934 HANO RD
SANTA FE NM
87505-3307
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5252
  • Fax:
Mailing address:
  • Phone: 505-982-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPAT 2799
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: