=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346378361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMAN J ROSS PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1106 SANTA FE TRL STE 2
-----------------------------------------------------
City | DUNCANVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75137-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-236-3999
-----------------------------------------------------
Fax | 469-293-4144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 SANTA FE TRL STE 2
-----------------------------------------------------
City | DUNCANVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75137-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-236-3999
-----------------------------------------------------
Fax | 469-293-4144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18030
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------