Healthcare Provider Details

I. General information

NPI: 1821693946
Provider Name (Legal Business Name): IESHA P ROSENBORO MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 INDUSTRIAL PARK DR STE C
WALDORF MD
20602-2729
US

IV. Provider business mailing address

11288 BURBERRY ST
WHITE PLAINS MD
20695-3187
US

V. Phone/Fax

Practice location:
  • Phone: 301-792-7207
  • Fax:
Mailing address:
  • Phone: 301-793-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC13623
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0060
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: