Provider Demographics
NPI:1194567834
Name:ROSS, ANTHONY N (LGSW)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:N
Last Name:ROSS
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DONOVAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4128
Mailing Address - Country:US
Mailing Address - Phone:218-360-2485
Mailing Address - Fax:
Practice Address - Street 1:109 DONOVAN DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4128
Practice Address - Country:US
Practice Address - Phone:218-360-2485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health