Provider Demographics
NPI:1770076200
Name:ROSS, KIMBERLY SUE (CDCA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:ROSS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-4403
Mailing Address - Country:US
Mailing Address - Phone:513-727-1438
Mailing Address - Fax:
Practice Address - Street 1:2005 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4403
Practice Address - Country:US
Practice Address - Phone:513-727-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140027101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)