Provider Demographics
NPI:1033683354
Name:ROEBACK, GREGORY A (LPC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:ROEBACK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-0761
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-438-7892
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:573-438-7892
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002061101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional