Provider Demographics
NPI:1568475952
Name:ROSSELOT, SUZZANNE C (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZZANNE
Middle Name:C
Last Name:ROSSELOT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUZZANNE
Other - Middle Name:C
Other - Last Name:ROSSELOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7000 E. GENESEE STREET,
Mailing Address - Street 2:LYNDON OFFICE PARK, BLDG C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1831
Mailing Address - Country:US
Mailing Address - Phone:315-446-6208
Mailing Address - Fax:315-446-4120
Practice Address - Street 1:7000 E GENESEE ST
Practice Address - Street 2:LYNDON OFFICE PARK, BLDG C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-446-6208
Practice Address - Fax:315-446-4120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR018525-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55286BMedicare ID - Type Unspecified