Provider Demographics
NPI:1043302326
Name:ROSENSHINE, ANITA S (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:S
Last Name:ROSENSHINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:R
Other - Last Name:KORNBLUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:533 DAVID WHITES LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-2822
Mailing Address - Country:US
Mailing Address - Phone:631-287-7021
Mailing Address - Fax:631-287-7337
Practice Address - Street 1:533 DAVID WHITES LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-2822
Practice Address - Country:US
Practice Address - Phone:631-287-7021
Practice Address - Fax:631-287-7337
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR023406-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN16851Medicare ID - Type UnspecifiedSOCIAL WORK PROVIDER