Provider Demographics
NPI:1487895769
Name:RUOCCO MCDONALD, SALLY (LCSW)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:RUOCCO MCDONALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 BARRETT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1413
Mailing Address - Country:US
Mailing Address - Phone:631-665-6707
Mailing Address - Fax:
Practice Address - Street 1:174 BARRETT AVE
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1413
Practice Address - Country:US
Practice Address - Phone:631-312-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072583-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY072583-1OtherLICENSE