1508931858 NPI number — MRS. ROSE ANN QUARESIMA LCSW

Table of content: MRS. ROSE ANN QUARESIMA LCSW (NPI 1508931858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508931858 NPI number — MRS. ROSE ANN QUARESIMA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUARESIMA
Provider First Name:
ROSE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
QUARESIMA PATRICK
Provider Other First Name:
ROSE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508931858
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 SOUTH FOURTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEKALB
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-787-2566
Provider Business Mailing Address Fax Number:
815-758-1430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 SOUTH FOURTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEKALB
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-787-2566
Provider Business Practice Location Address Fax Number:
815-758-1430
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01923314 . This is a "BLUE CROSS & BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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