Provider Demographics
NPI:1467765412
Name:DE LA ROSA, LILLIAN IVETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LILLIAN
Middle Name:IVETTE
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CROOKED HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717
Mailing Address - Country:US
Mailing Address - Phone:631-761-2546
Mailing Address - Fax:631-761-2282
Practice Address - Street 1:998 CROOKED HILL ROAD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-761-2082
Practice Address - Fax:631-761-2282
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074811-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical