Provider Demographics
NPI:1851422976
Name:ROSSER, MARTHA SQUIRES (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SQUIRES
Last Name:ROSSER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7401
Mailing Address - Country:US
Mailing Address - Phone:336-275-8619
Mailing Address - Fax:
Practice Address - Street 1:2311 W CONE BLVD
Practice Address - Street 2:SUITE 236
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-4042
Practice Address - Country:US
Practice Address - Phone:336-288-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0008711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6027-BOtherBLUE CROSS BLUE SHIELD