Basic Information
| Provider Information | |||||||||
| NPI: | 1144535915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 707 BROADWAY BLVD NE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1207 GOLF COURSE RD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059944100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.023540 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C-08261 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.