Healthcare Provider Details

I. General information

NPI: 1962682591
Provider Name (Legal Business Name): SAMUEL ROSARIO LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 OLD STREET RD SUITE 202
PETERBOROUGH NH
03458-1265
US

IV. Provider business mailing address

458 OLD STREET RD SUITE 202
PETERBOROUGH NH
03458-1265
US

V. Phone/Fax

Practice location:
  • Phone: 603-924-9490
  • Fax:
Mailing address:
  • Phone: 603-924-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number324
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRE161402
Identifier TypeOTHER
Identifier StateNH
Identifier IssuerMEDICARE PTAN
# 2
Identifier30426923
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: