Healthcare Provider Details

I. General information

NPI: 1326512419
Provider Name (Legal Business Name): ROSSDLYN PALACIO MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1894 WALTON AVE
BRONX NY
10453-6018
US

IV. Provider business mailing address

1894 WALTON AVE
BRONX NY
10453-6018
US

V. Phone/Fax

Practice location:
  • Phone: 347-949-3492
  • Fax: 718-583-3360
Mailing address:
  • Phone: 347-949-3492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number100007
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: