Provider Demographics
NPI:1609698836
Name:SMITH, ROSA LEE (MSC)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:57 BROOKWOOD DR APT C
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2723
Mailing Address - Country:US
Mailing Address - Phone:959-223-0187
Mailing Address - Fax:203-590-1197
Practice Address - Street 1:330 ROBERTS ST STE 103
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3654
Practice Address - Country:US
Practice Address - Phone:860-962-1803
Practice Address - Fax:203-590-1197
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT171M00000X, 101YP1600X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management