MEDICARE: MISS DESIREE KENYETTA ROSS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	CW016207	PA

General Provider Information

NPI Number	:	1457421737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DESIREE KENYETTA ROSS LCSW

Provider Business Mailing Address
First Line	:	89 SAGEWOOD DR
Second Line	:
City	:	MALVERN
State	:	PA
Zip	:	19355-2234
Country	:	US
Telephone Number	:	718-757-0643
Fax Number	:

Provider Business Practice Location Address
First Line	:	89 SAGEWOOD DR
Second Line	:
City	:	MALVERN
State	:	PA
Zip	:	19355-2234
Country	:	US
Telephone Number	:	718-757-0643
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	09/26/2023

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