Provider Demographics
NPI:1720593338
Name:ROLLO, MARY R (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:ROLLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6770 WEATHERED DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-2210
Mailing Address - Country:US
Mailing Address - Phone:850-384-1712
Mailing Address - Fax:
Practice Address - Street 1:112 W CERVANTES ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3128
Practice Address - Country:US
Practice Address - Phone:850-466-3200
Practice Address - Fax:850-466-3203
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW10074104100000X
FLSW15695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty