=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568475952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZZANNE C ROSSELOT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 E GENESEE ST LYNDON OFFICE PARK, BLDG C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-446-6208
-----------------------------------------------------
Fax | 315-446-4120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7000 E. GENESEE STREET, LYNDON OFFICE PARK, BLDG C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-446-6208
-----------------------------------------------------
Fax | 315-446-4120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | PR018525-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------