Basic Information
| Provider Information | |||||||||
| NPI: | 1003151507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSERMAN | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 FOREST EDGE CT | ||||||||
| Address2: | #304D | ||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211132830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105701694 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2405 FOREST EDGE CT | ||||||||
| Address2: | APT. 304D | ||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211132830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105701694 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2012 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 15010 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.