Provider Demographics
NPI:1962015388
Name:ROSEBERRY, SONYA
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SONYA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35425 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-9800
Mailing Address - Country:US
Mailing Address - Phone:734-467-7600
Mailing Address - Fax:
Practice Address - Street 1:22010 EASTWOOD ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2858
Practice Address - Country:US
Practice Address - Phone:248-259-5267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382849658Medicaid