Provider Demographics
NPI:1003203340
Name:MARYANN LAROSA,LCSW/R
Entity Type:Organization
Organization Name:MARYANN LAROSA,LCSW/R
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW/R
Authorized Official - Phone:631-737-2727
Mailing Address - Street 1:233 UNION AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1820
Mailing Address - Country:US
Mailing Address - Phone:631-737-2727
Mailing Address - Fax:631-585-8591
Practice Address - Street 1:233 UNION AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1820
Practice Address - Country:US
Practice Address - Phone:631-737-2727
Practice Address - Fax:631-585-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050562305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN8L541OtherPTAN