Provider Demographics
NPI:1598047805
Name:ROLON, GENIA (CASAC TRAINEE)
Entity Type:Individual
Prefix:
First Name:GENIA
Middle Name:
Last Name:ROLON
Suffix:
Gender:F
Credentials:CASAC TRAINEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 VICTORY BLVD
Mailing Address - Street 2:BASEMENT
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1688 VICTORY BLVD
Practice Address - Street 2:BASEMENT
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3547
Practice Address - Country:US
Practice Address - Phone:718-447-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25666101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY25666OtherCASAC TRAINEE