Provider Demographics
NPI:1417218165
Name:ROBERTS, JOHN DAVID (LCPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 SOLOMONS ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-8876
Mailing Address - Country:US
Mailing Address - Phone:410-257-5200
Mailing Address - Fax:410-257-2442
Practice Address - Street 1:6045 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-8876
Practice Address - Country:US
Practice Address - Phone:410-257-5200
Practice Address - Fax:410-257-2442
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4908101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561800Medicaid