Provider Demographics
NPI:1245253376
Name:ROSS, MARILYN (LCSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE Q-1
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8661
Mailing Address - Country:US
Mailing Address - Phone:512-345-3139
Mailing Address - Fax:512-345-3139
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE Q-1
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-345-3139
Practice Address - Fax:512-345-3139
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS13665101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S74POtherBCBS
TX1082588-02Medicaid
TX00S74PMedicare ID - Type Unspecified