Provider Demographics
NPI:1861957920
Name:ROMAN, MARY (LCSWA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 IRONWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6292
Mailing Address - Country:US
Mailing Address - Phone:808-222-5174
Mailing Address - Fax:
Practice Address - Street 1:6245 CLIFFDALE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2126
Practice Address - Country:US
Practice Address - Phone:808-222-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013056104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker