Provider Demographics
NPI:1942747092
Name:ROCHESTER, TINA
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:ROCHESTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:161 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2879
Mailing Address - Country:US
Mailing Address - Phone:631-360-7578
Mailing Address - Fax:
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2879
Practice Address - Country:US
Practice Address - Phone:631-360-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097912-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker