Provider Demographics
NPI:1992709570
Name:ROSS, MARION CHRISTINE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARION
Middle Name:CHRISTINE
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 EXECUTIVE DR STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8440
Mailing Address - Country:US
Mailing Address - Phone:601-665-2047
Mailing Address - Fax:800-476-4191
Practice Address - Street 1:133 EXECUTIVE DR STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-665-2047
Practice Address - Fax:800-476-4191
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC2287104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04478331Medicaid
MS04478331Medicaid
MSQ23657Medicare UPIN