Provider Demographics
NPI:1093180374
Name:BRACY, ROSHANNA
Entity Type:Individual
Prefix:
First Name:ROSHANNA
Middle Name:
Last Name:BRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 MADALINE DR
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1367
Mailing Address - Country:US
Mailing Address - Phone:201-921-5977
Mailing Address - Fax:
Practice Address - Street 1:117-119 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060
Practice Address - Country:US
Practice Address - Phone:908-756-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056568001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical