MEDICARE: MS. MARYANN LA ROSA LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	050562	NY

General Provider Information

NPI Number	:	1396843637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYANN LA ROSA LCSW-R

Provider Business Mailing Address
First Line	:	233 UNION AVE
Second Line	:	SUITE 202
City	:	HOLBROOK
State	:	NY
Zip	:	11741-1820
Country	:	US
Telephone Number	:	631-737-2727
Fax Number	:	631-737-2727

Provider Business Practice Location Address
First Line	:	233 UNION AVE
Second Line	:	SUITE 202
City	:	HOLBROOK
State	:	NY
Zip	:	11741-1820
Country	:	US
Telephone Number	:	631-737-2727
Fax Number	:	631-737-2727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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