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General NPI Number Information
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NPI Number | 1205276292
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Entity Type | Individual
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Provider Name | ETHEL ROSS DEVELOPMENTAL INTERV
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Gender | Female
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Dates
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Enumeration Date | 07/05/2013
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Last Update Date | 07/05/2013
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Provider Practice Location Address
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Address Line | 315 ROLLING ACRES RD
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City | BEAYTYVILLE
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State | KY
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Zip | 40311
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Country | US
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Telephone | 606-560-0081
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 726
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City | BEATTYVILLE
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State | KY
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Zip | 41311
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Country | US
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Telephone | 606-560-0081
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | 201149812
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License Number State | KY
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