Provider Demographics
NPI:1386608685
Name:ROSS, GLORIA J (PHD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HARBERT DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-5117
Mailing Address - Country:US
Mailing Address - Phone:937-208-7575
Mailing Address - Fax:937-208-7590
Practice Address - Street 1:111 HARBERT DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-5117
Practice Address - Country:US
Practice Address - Phone:937-208-7575
Practice Address - Fax:937-208-7590
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOHIO4727103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0990629Medicaid
OH0990629Medicaid
R72280Medicare UPIN
OHCP34391Medicare PIN