Healthcare Provider Details

I. General information

NPI: 1720392509
Provider Name (Legal Business Name): LARRY COMPA CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

IV. Provider business mailing address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2500
  • Fax:
Mailing address:
  • Phone: 585-922-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8188
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: