=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821693946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IESHA P ROSENBORO MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2020
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 INDUSTRIAL PARK DR STE C
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-792-7207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11288 BURBERRY ST
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20695-3187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-793-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 0060
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LC13623
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------