Healthcare Provider Details

I. General information

NPI: 1598959546
Provider Name (Legal Business Name): ERICA LATOYA ROSEBORO MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MERRICK ST
WORCESTER MA
01609-1937
US

IV. Provider business mailing address

585 LINCOLN ST
WORCESTER MA
01605-1906
US

V. Phone/Fax

Practice location:
  • Phone: 508-797-6100
  • Fax: 508-797-0693
Mailing address:
  • Phone: 508-854-3320
  • Fax: 508-753-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1306421
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierM18684
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS MH
# 3
Identifier1308785
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 4
Identifier2220002001
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS
# 5
IdentifierY10400
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMEDICARE GROUP NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: