Provider Demographics
NPI:1215090923
Name:ROLON, IVETTE
Entity type:Individual
Prefix:MS
First Name:IVETTE
Middle Name:
Last Name:ROLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 EAST 105TH STREET APT. 4C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:917-492-2572
Mailing Address - Fax:
Practice Address - Street 1:FORDHAM, TREMONT
Practice Address - Street 2:260 EAST 188TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5302
Practice Address - Country:US
Practice Address - Phone:718-960-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZP60477FMedicaid