=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619427119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. ROSHANDA ROBERTS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2016
-----------------------------------------------------
Last Update Date | 04/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10990 WILSHIRE BLVD STE 250
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-262-8203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1253
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90251-1253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-262-8203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 119189
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------