Provider Demographics
NPI:1992427306
Name:DIAZROSSO, KIMBERLY (LMSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DIAZROSSO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4015
Mailing Address - Country:US
Mailing Address - Phone:917-435-8317
Mailing Address - Fax:
Practice Address - Street 1:107 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2337
Practice Address - Country:US
Practice Address - Phone:631-666-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker