Provider Demographics
NPI:1770801078
Name:SANDBERG, ROGER KENNETH (LCPC)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:KENNETH
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5205
Mailing Address - Street 2:
Mailing Address - City:LAYTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20882-0205
Mailing Address - Country:US
Mailing Address - Phone:301-452-2743
Mailing Address - Fax:
Practice Address - Street 1:2911 OLNEY SANDY SPRING RD STE A
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-3506
Practice Address - Country:US
Practice Address - Phone:301-452-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1046101YP2500X, 101YM0800X
CAMFC29326106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health