Healthcare Provider Details

I. General information

NPI: 1144530940
Provider Name (Legal Business Name): ROBERT BRUCE RISAVI LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5957 ROUTE 20 WEST
LAFAYETTE NY
13084
US

IV. Provider business mailing address

5957 ROUTE 20 WEST
LAFAYETTE NY
13084
US

V. Phone/Fax

Practice location:
  • Phone: 315-677-3152
  • Fax: 315-677-3154
Mailing address:
  • Phone: 315-677-3152
  • Fax: 315-677-3154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number073125-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: