Provider Demographics
NPI:1457796146
Name:DIMAMBRO, ROBERTO C (CASAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:C
Last Name:DIMAMBRO
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SULLIVAN LN
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:NY
Mailing Address - Zip Code:12809-1102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 GLENRIDGE RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4523
Practice Address - Country:US
Practice Address - Phone:518-952-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12213101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid