Provider Demographics
NPI:1164567178
Name:ROSS, KATHLEEN D (MA LPC)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:D
Last Name:ROSS
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W MAIN ST STE 2-9
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-2331
Mailing Address - Country:US
Mailing Address - Phone:860-378-4996
Mailing Address - Fax:
Practice Address - Street 1:8 W MAIN ST STE 2-9
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-2331
Practice Address - Country:US
Practice Address - Phone:860-378-4996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty