Provider Demographics
NPI:1083059489
Name:FENELON, ROSE REGINE (MS)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:REGINE
Last Name:FENELON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CROYDON CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6143
Mailing Address - Country:US
Mailing Address - Phone:516-280-0078
Mailing Address - Fax:
Practice Address - Street 1:3 CROYDON CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6143
Practice Address - Country:US
Practice Address - Phone:516-280-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY904B101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherEI/CERTIFICATION