Healthcare Provider Details

I. General information

NPI: 1881340602
Provider Name (Legal Business Name): RAISSA MARIE ROSARIO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10803A ST VITH WAY
FORT DRUM NY
13603-3118
US

IV. Provider business mailing address

10803A ST VITH WAY
FORT DRUM NY
13603-3118
US

V. Phone/Fax

Practice location:
  • Phone: 787-398-0044
  • Fax:
Mailing address:
  • Phone: 787-398-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17412
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.106645
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: