Provider Demographics
NPI:1972761526
Name:ROSTOCKI, NELLIE M (LADCI)
Entity type:Individual
Prefix:
First Name:NELLIE
Middle Name:M
Last Name:ROSTOCKI
Suffix:
Gender:F
Credentials:LADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-3064
Mailing Address - Country:US
Mailing Address - Phone:508-222-7525
Mailing Address - Fax:508-223-4453
Practice Address - Street 1:140 PARK ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-3064
Practice Address - Country:US
Practice Address - Phone:508-222-7525
Practice Address - Fax:508-223-4453
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1870101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA130961Medicaid