Provider Demographics
NPI:1699245928
Name:ROSS, MISTY JOHNETTA
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:JOHNETTA
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CEDAR CREEK DR APT 913
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2349
Mailing Address - Country:US
Mailing Address - Phone:318-564-7436
Mailing Address - Fax:
Practice Address - Street 1:2942 KNIGHT ST.
Practice Address - Street 2:BLDG. 4 SUITE 426
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-754-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator