Provider Demographics
NPI:1881974855
Name:ROCCOBERTON, MARJORIE RUTH (MARJORIE ROCCOBERTON)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:RUTH
Last Name:ROCCOBERTON
Suffix:
Gender:F
Credentials:MARJORIE ROCCOBERTON
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:RUTH
Other - Last Name:ROCCOBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:82 SHODDY MILL RD.
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-7818
Mailing Address - Country:US
Mailing Address - Phone:860-977-0630
Mailing Address - Fax:
Practice Address - Street 1:82 SHODDY MILL RD
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7818
Practice Address - Country:US
Practice Address - Phone:860-977-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2102085697101YS0200X
CT000292106H00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000292OtherLICENSED PROFESSIONAL COUNSELOR
CT2102085697OtherCERTIFIED SCHOOL COUNSELOR