Provider Demographics
NPI:1669002317
Name:ROSENBACH, SANDRA LEE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:ROSENBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 PENNINGTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21226-1405
Mailing Address - Country:US
Mailing Address - Phone:917-816-6786
Mailing Address - Fax:
Practice Address - Street 1:4710 PENNINGTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21226-1405
Practice Address - Country:US
Practice Address - Phone:917-816-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker