Provider Demographics
NPI:1063788511
Name:ROSS, BENJAMIN M (BS, CDP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:ROSS
Suffix:
Gender:M
Credentials:BS, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16715 AURORA AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133
Mailing Address - Country:US
Mailing Address - Phone:206-546-9766
Mailing Address - Fax:
Practice Address - Street 1:16715 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5310
Practice Address - Country:US
Practice Address - Phone:206-546-9766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001549101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)