Healthcare Provider Details

I. General information

NPI: 1801226626
Provider Name (Legal Business Name): STACI R ROSS PHD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 S 6TH ST
LAS VEGAS NV
89101-6922
US

IV. Provider business mailing address

716 S 6TH ST
LAS VEGAS NV
89101-6922
US

V. Phone/Fax

Practice location:
  • Phone: 702-382-1960
  • Fax: 702-382-4993
Mailing address:
  • Phone: 702-382-1960
  • Fax: 702-382-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY0406
License Number StateNV

VIII. Authorized Official

Name: STACI R ROSS
Title or Position: OWNER
Credential: PHD INC
Phone: 702-382-1960