Healthcare Provider Details

I. General information

NPI: 1457515264
Provider Name (Legal Business Name): MESHELLE K TANTILLO CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 UNIVERSITY AVE SUITE 7
ROCHESTER NY
14607-1647
US

IV. Provider business mailing address

PO BOX 31094
HARTFORD CT
06150-1094
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-8422
  • Fax: 585-442-8494
Mailing address:
  • Phone: 518-952-8140
  • Fax: 518-952-8287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: