Provider Demographics
NPI:1497242226
Name:ROSENBERG, CARL WILLIS (LMFT)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:WILLIS
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RASPBERRY RD
Mailing Address - Street 2:
Mailing Address - City:STEDMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28391-9725
Mailing Address - Country:US
Mailing Address - Phone:910-635-9545
Mailing Address - Fax:910-491-8902
Practice Address - Street 1:2525 RAEFORD RD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5092
Practice Address - Country:US
Practice Address - Phone:910-635-9545
Practice Address - Fax:910-491-8902
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194124412Medicaid