MEDICARE: SUZZANNE C ROSSELOT LCSW

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	PR018525-1	NY

General Provider Information

NPI Number	:	1568475952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZZANNE C ROSSELOT LCSW

Provider Business Mailing Address
First Line	:	7000 E. GENESEE STREET,
Second Line	:	LYNDON OFFICE PARK, BLDG C
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1831
Country	:	US
Telephone Number	:	315-446-6208
Fax Number	:	315-446-4120

Provider Business Practice Location Address
First Line	:	7000 E GENESEE ST
Second Line	:	LYNDON OFFICE PARK, BLDG C
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1131
Country	:	US
Telephone Number	:	315-446-6208
Fax Number	:	315-446-4120

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	07/08/2007

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