Provider Demographics
NPI:1942372701
Name:PERSICO, ROSE ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:ELLEN
Last Name:PERSICO
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 1:39 WALL ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4705
Mailing Address - Country:US
Mailing Address - Phone:860-704-8128
Mailing Address - Fax:
Practice Address - Street 1:351 SILVER ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3919
Practice Address - Country:US
Practice Address - Phone:860-262-5220
Practice Address - Fax:860-262-5367
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical