MEDICARE: RAISSA MARIE ROSARIO LSW

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	17412	PR
2	1041C0700X	Clinical Social Worker	150.106645	IL

General Provider Information

NPI Number	:	1881340602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAISSA MARIE ROSARIO LSW

Provider Business Mailing Address
First Line	:	10803A ST VITH WAY
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3118
Country	:	US
Telephone Number	:	787-398-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	10803A ST VITH WAY
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3118
Country	:	US
Telephone Number	:	787-398-0044
Fax Number	:

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

Provider Enumeration Date	:	03/02/2022
Last Update Date	:	05/19/2026

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Directions to “ RAISSA MARIE ROSARIO LSW” Practice Location

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