Provider Demographics
NPI:1639102403
Name:VAZQUEZ-SANTIAGO, ROSE I (LCSW,ACSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:I
Last Name:VAZQUEZ-SANTIAGO
Suffix:
Gender:F
Credentials:LCSW,ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-7048
Mailing Address - Country:US
Mailing Address - Phone:203-284-2800
Mailing Address - Fax:203-294-8734
Practice Address - Street 1:50 GAYLORD FARM RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2899
Practice Address - Country:US
Practice Address - Phone:203-284-2800
Practice Address - Fax:203-294-8734
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00-3886891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical