Provider Demographics
NPI:1891897567
Name:STRUK, ROSEMARIE C (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:C
Last Name:STRUK
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 1:77 FOX CT
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2614
Mailing Address - Country:US
Mailing Address - Phone:631-909-2317
Mailing Address - Fax:
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3712
Practice Address - Country:US
Practice Address - Phone:631-920-8300
Practice Address - Fax:631-920-8460
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074024-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN179L1Medicare PIN