Provider Demographics
NPI:1821693946
Name:ROSENBORO, IESHA P (MS)
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:P
Last Name:ROSENBORO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11288 BURBERRY ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-3187
Mailing Address - Country:US
Mailing Address - Phone:301-793-3800
Mailing Address - Fax:
Practice Address - Street 1:2 INDUSTRIAL PARK DR STE C
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2729
Practice Address - Country:US
Practice Address - Phone:301-792-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC0060175T00000X
MDLC13623101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC13623OtherBOARD OF PROFESSIONAL COUNSELORS
DC0060OtherDCAPC CERTIFIED PEER RECOVERY SPECIALIST