Provider Demographics
NPI:1396843637
Name:LA ROSA, MARYANN (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:
Last Name:LA ROSA
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:631-737-2727
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:631-737-2727
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0505621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN8L541Medicare ID - Type Unspecified