Provider Demographics
NPI:1588044994
Name:ROSEBORO, STEPHANIE (CRC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ROSEBORO
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:ROSEBORO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCA
Mailing Address - Street 1:4825 COMMERCIAL PLAZA ST APT 91A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4671
Mailing Address - Country:US
Mailing Address - Phone:704-692-0207
Mailing Address - Fax:
Practice Address - Street 1:4825 COMMERCIAL PLAZA ST APT 91A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4671
Practice Address - Country:US
Practice Address - Phone:704-692-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00119466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA11664OtherNC BORD OF LICENSED PROFESSIONAL COUNSELORS