Provider Demographics
NPI:1659814531
Name:ROSENBORO, MIKEL
Entity Type:Individual
Prefix:MR
First Name:MIKEL
Middle Name:
Last Name:ROSENBORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11871 HOLABIRD LN
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-5204
Mailing Address - Country:US
Mailing Address - Phone:202-421-0431
Mailing Address - Fax:
Practice Address - Street 1:11546 HORNBEAM CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-5298
Practice Address - Country:US
Practice Address - Phone:202-421-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty