Provider Demographics
NPI:1083008684
Name:ROBERTS, LAURA (MSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-2619
Mailing Address - Country:US
Mailing Address - Phone:920-207-0651
Mailing Address - Fax:
Practice Address - Street 1:2209 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-4281
Practice Address - Country:US
Practice Address - Phone:920-892-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1675-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083008684Medicaid