Provider Demographics
NPI:1912159849
Name:ST. ROSE, ROSLYN (CASAC-T)
Entity Type:Individual
Prefix:
First Name:ROSLYN
Middle Name:
Last Name:ST. ROSE
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4436
Mailing Address - Country:US
Mailing Address - Phone:631-920-8000
Mailing Address - Fax:
Practice Address - Street 1:240A LONG ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3123
Practice Address - Country:US
Practice Address - Phone:631-920-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21552-T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)