Healthcare Provider Details

I. General information

NPI: 1992684914
Provider Name (Legal Business Name): GRACE ROSE SOTTILO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 112
CORAM NY
11727-4116
US

IV. Provider business mailing address

3600 ROUTE 112
CORAM NY
11727-4116
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: