Provider Demographics
NPI:1477958676
Name:SERVELLON, ROXANA MARISOL (LCSW, CASAC)
Entity Type:Individual
Prefix:MISS
First Name:ROXANA
Middle Name:MARISOL
Last Name:SERVELLON
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1134
Mailing Address - Country:US
Mailing Address - Phone:516-547-8610
Mailing Address - Fax:
Practice Address - Street 1:15 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1134
Practice Address - Country:US
Practice Address - Phone:516-547-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2-22379101YA0400X
NY0842221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)