Provider Demographics
NPI:1366768608
Name:HARRIS, ROSHUN J (MA, LCPC)
Entity type:Individual
Prefix:
First Name:ROSHUN
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 LORD BALTIMORE DR
Mailing Address - Street 2:SUITE A102
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2673
Mailing Address - Country:US
Mailing Address - Phone:410-903-3178
Mailing Address - Fax:866-623-6129
Practice Address - Street 1:2505 LORD BALTIMORE DR
Practice Address - Street 2:SUITE A102
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2673
Practice Address - Country:US
Practice Address - Phone:410-903-3178
Practice Address - Fax:866-623-6129
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3404101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD030347000Medicaid