Provider Demographics
NPI:1235476532
Name:VASSALLO, ROSEMARY (LCSW-R)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:ROSEMARY
Other - Middle Name:
Other - Last Name:TRAVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:3767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1890
Practice Address - Country:US
Practice Address - Phone:518-623-2844
Practice Address - Fax:518-623-3416
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0272561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03543859Medicaid