Provider Demographics
NPI:1295800563
Name:ROSEN, LAURIE S (LCSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:S
Last Name:ROSEN
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 1:169 COMMACK RD STE H135
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3442
Mailing Address - Country:US
Mailing Address - Phone:631-864-1469
Mailing Address - Fax:631-360-0706
Practice Address - Street 1:222 E MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2814
Practice Address - Country:US
Practice Address - Phone:631-864-1469
Practice Address - Fax:631-360-0706
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO185141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N06791Medicare ID - Type Unspecified