Provider Demographics
NPI:1992141477
Name:ROSS, HEATHER I (LAC)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:I
Last Name:ROSS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GEORGANN RD
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3224
Mailing Address - Country:US
Mailing Address - Phone:631-875-3489
Mailing Address - Fax:
Practice Address - Street 1:11 GEORGANN RD
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3224
Practice Address - Country:US
Practice Address - Phone:631-875-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-11
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25-003674171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist