MEDICARE: DR. BART LEE ROSS PH.D

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	103TC0700X	Clinical Psychologist	PSY15175	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639105430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BART LEE ROSS PH.D

Provider Business Mailing Address
First Line	:	16531 BOLSA CHICA ST
Second Line	:	STE 314
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3596
Country	:	US
Telephone Number	:	323-791-1808
Fax Number	:

Provider Business Practice Location Address
First Line	:	16531 BOLSA CHICA ST
Second Line	:	STE 314
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3596
Country	:	US
Telephone Number	:	626-963-4467
Fax Number	:

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	02/17/2016

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