MEDICARE: BENJAMIN ROSS

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	101Y00000X	Counselor
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1518413269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN ROSS

Provider Business Mailing Address
First Line	:	526 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5306
Country	:	US
Telephone Number	:	269-321-9556
Fax Number	:

Provider Business Practice Location Address
First Line	:	526 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5306
Country	:	US
Telephone Number	:	269-321-9556
Fax Number	:

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

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	07/21/2022

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Directions to “ BENJAMIN ROSS ” Practice Location

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