Provider Demographics
NPI:1093745192
Name:MASTOWSKI, CONNIE MARIE (LCSW/R)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:MASTOWSKI
Suffix:
Gender:F
Credentials:LCSW/R
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:MARIE
Other - Last Name:GUERRIERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3399 WINTON RD S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3057
Mailing Address - Country:US
Mailing Address - Phone:585-334-6000
Mailing Address - Fax:585-334-2858
Practice Address - Street 1:3399 WINTON RD S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3057
Practice Address - Country:US
Practice Address - Phone:585-334-6000
Practice Address - Fax:585-334-2858
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0528781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355344Medicaid
NY11546334OtherCAQH
NY00355344Medicaid