Healthcare Provider Details

I. General information

NPI: 1467547620
Provider Name (Legal Business Name): LISA ANN ROSS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N OLIVE ST
MEDIA PA
19063-2418
US

IV. Provider business mailing address

2400 HOLLIS RD
HAVERTOWN PA
19083-1522
US

V. Phone/Fax

Practice location:
  • Phone: 610-566-7540
  • Fax: 610-566-7677
Mailing address:
  • Phone: 610-924-0609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCW01490PA
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW01490
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: