Basic Information
Provider Information | |||||||||
NPI: | 1861762528 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, LCAS-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 336 DEERFIELD RD | ||||||||
Address2: |   | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286075008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282624100 | ||||||||
FaxNumber: | 8282624103 | ||||||||
Practice Location | |||||||||
Address1: | 950 STATE FARM RD | ||||||||
Address2: |   | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286075021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287377600 | ||||||||
FaxNumber: | 8287377612 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2012 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C010407 | NC | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | C010407 | NC | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.