Healthcare Provider Details

I. General information

NPI: 1467653097
Provider Name (Legal Business Name): JUDITH ALICIA ROSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 MONTAUK HWY
EAST QUOGUE NY
11942-3919
US

IV. Provider business mailing address

429 MONTAUK HWY
EAST QUOGUE NY
11942-3919
US

V. Phone/Fax

Practice location:
  • Phone: 631-653-8664
  • Fax: 631-653-3934
Mailing address:
  • Phone: 631-653-8664
  • Fax: 631-653-3934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberRO46867-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: