Provider Demographics
NPI:1518775709
Name:OSBORNE, LOLETTA R
Entity type:Individual
Prefix:
First Name:LOLETTA
Middle Name:R
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOLETTA
Other - Middle Name:
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19425
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-0425
Mailing Address - Country:US
Mailing Address - Phone:443-561-4779
Mailing Address - Fax:
Practice Address - Street 1:4128 HAYWARD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4340
Practice Address - Country:US
Practice Address - Phone:410-314-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health