Provider Demographics
NPI:1336456557
Name:ROBERTS, JUSTINE JAI
Entity Type:Individual
Prefix:MS
First Name:JUSTINE
Middle Name:JAI
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JUSTINE
Other - Middle Name:JAI
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW-C
Mailing Address - Street 1:1714 N. CAROLINE STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213
Mailing Address - Country:US
Mailing Address - Phone:410-837-5612
Mailing Address - Fax:
Practice Address - Street 1:2512 N CHARLES ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4645
Practice Address - Country:US
Practice Address - Phone:443-956-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD074021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13008-1400Medicare PIN