Healthcare Provider Details

I. General information

NPI: 1134060411
Provider Name (Legal Business Name): RAEQUAN ROSE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WASHINGTON BLVD
BALTIMORE MD
21230-2350
US

IV. Provider business mailing address

6221 GREENLEIGH AVE UNIT 403
MIDDLE RIVER MD
21220-2029
US

V. Phone/Fax

Practice location:
  • Phone: 410-343-4343
  • Fax:
Mailing address:
  • Phone: 631-522-3176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number32677
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: