Provider Demographics
NPI:1699033316
Name:ROSOFF, RICHARD (CIT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ROSOFF
Suffix:
Gender:M
Credentials:CIT
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 417153
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7153
Mailing Address - Country:US
Mailing Address - Phone:518-952-8140
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:55 ELM ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3549
Practice Address - Country:US
Practice Address - Phone:518-793-7273
Practice Address - Fax:518-798-5004
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25550101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03008326Medicaid