Provider Demographics
NPI:1447097423
Name:DANIEL, ROSHANDA
Entity type:Individual
Prefix:
First Name:ROSHANDA
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3699 GETWELL RD
Mailing Address - Street 2:STE 3 BLDG E
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672
Mailing Address - Country:US
Mailing Address - Phone:901-610-1720
Mailing Address - Fax:
Practice Address - Street 1:3699 GETWELL RD
Practice Address - Street 2:STE 3 BLDG E
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672
Practice Address - Country:US
Practice Address - Phone:901-610-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-1063101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor