Provider Demographics
NPI:1811274566
Name:ROOSA, MARY (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:ROOSA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3833
Mailing Address - Country:US
Mailing Address - Phone:845-338-1945
Mailing Address - Fax:
Practice Address - Street 1:345 MOUNTAIN VIEW AVENUE
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-0549
Practice Address - Country:US
Practice Address - Phone:845-338-1945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006248235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist