Healthcare Provider Details

I. General information

NPI: 1265140834
Provider Name (Legal Business Name): ALYSSA ROSE D'AGOSTINO LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 MONROE AVE
ROCHESTER NY
14618-3032
US

IV. Provider business mailing address

2376 MONROE AVE
ROCHESTER NY
14618-3032
US

V. Phone/Fax

Practice location:
  • Phone: 585-430-9877
  • Fax: 585-200-3215
Mailing address:
  • Phone: 585-430-9877
  • Fax: 585-200-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberP113019
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: