Provider Demographics
NPI:1225017064
Name:ROBERTS, LAURIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2704
Mailing Address - Country:US
Mailing Address - Phone:715-526-3666
Mailing Address - Fax:715-526-3666
Practice Address - Street 1:310 S BARTLETT ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2704
Practice Address - Country:US
Practice Address - Phone:715-526-3666
Practice Address - Fax:715-526-3666
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010836501041C0700X
WI7483-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008970100OtherBLUE CROSS/BLUE SHIELD
MIOP02350Medicare ID - Type UnspecifiedMEDICARE PART B