Provider Demographics
NPI:1104567197
Name:ROSS, RAYLENE (NCC, LPC, LCPC)
Entity type:Individual
Prefix:
First Name:RAYLENE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:NCC, LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 PELHAM DR STE F225
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-0601
Mailing Address - Country:US
Mailing Address - Phone:803-386-8375
Mailing Address - Fax:
Practice Address - Street 1:4500 FORT JACKSON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1134
Practice Address - Country:US
Practice Address - Phone:803-386-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9595101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health