Basic Information
| Provider Information | |||||||||
| NPI: | 1134397003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DI SANTO | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859223144 | ||||||||
| FaxNumber: | 5859221399 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 E RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146211229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222561 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW126465 | PA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 052530 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | R052530 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.