Basic Information
| Provider Information | |||||||||
| NPI: | 1417692872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLES | ||||||||
| FirstName: | LATASHA | ||||||||
| MiddleName: | GENELL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LGPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4022 DUDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212132139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432086156 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 N HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212185909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434386742 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2022 | ||||||||
| LastUpdateDate: | 04/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LGP12518 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.