Provider Demographics
NPI:1811478274
Name:PROPHETE, ROLANDA SANTOS (LICSW)
Entity type:Individual
Prefix:
First Name:ROLANDA
Middle Name:SANTOS
Last Name:PROPHETE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-2039
Mailing Address - Country:US
Mailing Address - Phone:617-349-6843
Mailing Address - Fax:
Practice Address - Street 1:18 SARGENT AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145
Practice Address - Country:US
Practice Address - Phone:617-792-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
MA111890101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool