Provider Demographics
NPI:1285690891
Name:MONGELLUZZO, ROXANE (MSW LCSW)
Entity type:Individual
Prefix:
First Name:ROXANE
Middle Name:
Last Name:MONGELLUZZO
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 S PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-4003
Mailing Address - Country:US
Mailing Address - Phone:724-626-8420
Mailing Address - Fax:724-628-0898
Practice Address - Street 1:416 S PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-4003
Practice Address - Country:US
Practice Address - Phone:724-626-8420
Practice Address - Fax:724-628-0898
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW008629L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA115676Medicaid
PA628649OtherBCBS
PA050793Medicare ID - Type Unspecified