Provider Demographics
NPI:1578837753
Name:CLEMENTS, ROSALIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSALIE
Middle Name:
Last Name:CLEMENTS
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 1:15 TOMKINS CT
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4020
Mailing Address - Country:US
Mailing Address - Phone:631-499-1208
Mailing Address - Fax:
Practice Address - Street 1:525 HALF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5828
Practice Address - Country:US
Practice Address - Phone:631-592-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730723651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1407982465OtherHALF HOLLOW HILLS CENTRAL SCHOOL DISTRICT