Healthcare Provider Details

I. General information

NPI: 1184841009
Provider Name (Legal Business Name): REGINA M ROSSETTO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 W CERMAK RD
CICERO IL
60804-2817
US

IV. Provider business mailing address

4944 W OAKDALE AVE
CHICAGO IL
60641-5122
US

V. Phone/Fax

Practice location:
  • Phone: 708-656-6430
  • Fax: 708-656-6591
Mailing address:
  • Phone: 773-725-2448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: