Provider Demographics
NPI:1790020782
Name:ROXBERRY, EMILY MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:ROXBERRY
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 DETOUR RD
Mailing Address - Street 2:
Mailing Address - City:GREAT CACAPON
Mailing Address - State:WV
Mailing Address - Zip Code:25422-3105
Mailing Address - Country:US
Mailing Address - Phone:610-750-0326
Mailing Address - Fax:
Practice Address - Street 1:2975 DETOUR RD
Practice Address - Street 2:
Practice Address - City:GREAT CACAPON
Practice Address - State:WV
Practice Address - Zip Code:25422-3105
Practice Address - Country:US
Practice Address - Phone:610-750-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009462991041C0700X
PACW0189651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1790020782Medicaid