Provider Demographics
NPI:1740640440
Name:ROSS, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
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 1:400 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6301017008103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351866298Medicaid