Provider Demographics
NPI:1366586315
Name:ROSS, SHELLEY M (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SHELLEY
Other - Middle Name:MICHAEL
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:919 ROSEMARY AVE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-3941
Mailing Address - Country:US
Mailing Address - Phone:760-966-1304
Mailing Address - Fax:
Practice Address - Street 1:919 ROSEMARY AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-3941
Practice Address - Country:US
Practice Address - Phone:760-966-1304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0260602Medicare UPIN
HI00B0260600Medicare UPIN