Provider Demographics
NPI:1275802548
Name:ROSSETTIE, KATHLEEN SANTILLI (MA CCC-SP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SANTILLI
Last Name:ROSSETTIE
Suffix:
Gender:F
Credentials:MA CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3104
Mailing Address - Country:US
Mailing Address - Phone:607-962-6930
Mailing Address - Fax:
Practice Address - Street 1:62 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3104
Practice Address - Country:US
Practice Address - Phone:607-962-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNEW YORKMedicaid