Provider Demographics
NPI:1114399847
Name:SLACK, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:185 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2102
Mailing Address - Country:US
Mailing Address - Phone:315-798-5249
Mailing Address - Fax:315-731-3491
Practice Address - Street 1:185 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2102
Practice Address - Country:US
Practice Address - Phone:315-798-5249
Practice Address - Fax:315-731-3491
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0474268Medicaid