Healthcare Provider Details

I. General information

NPI: 1376827196
Provider Name (Legal Business Name): GIDGET Q.V. RAFUS-ROUSELL CASAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 STATE HIGHWAY 310 STE 1 ST. LAWRENCE COUNTY COMMUNITY
CANTON NY
13617-1436
US

IV. Provider business mailing address

80 STATE HIGHWAY 310 STE 1
CANTON NY
13617-1436
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-2167
  • Fax:
Mailing address:
  • Phone: 315-386-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22453
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005006-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: