Provider Demographics
NPI:1003151507
Name:WASSERMAN, ROBERTA LYNN (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:LYNN
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 FOREST EDGE CT
Mailing Address - Street 2:#304D
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2830
Mailing Address - Country:US
Mailing Address - Phone:410-570-1694
Mailing Address - Fax:
Practice Address - Street 1:2405 FOREST EDGE CT
Practice Address - Street 2:APT. 304D
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-2830
Practice Address - Country:US
Practice Address - Phone:410-570-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health