Provider Demographics
NPI:1861957185
Name:ROSS, MARY M
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:JOOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR - IL/MO
Mailing Address - Street 1:1438 WILLOW BROOK CV APT 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4964
Mailing Address - Country:US
Mailing Address - Phone:314-303-9463
Mailing Address - Fax:
Practice Address - Street 1:SHERBROOKE VILLAGE
Practice Address - Street 2:4005 RIPA AVE
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125
Practice Address - Country:US
Practice Address - Phone:314-544-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003366225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist