Provider Demographics
NPI:1285642413
Name:ROEBUCK, MARK MORGAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:MORGAN
Last Name:ROEBUCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 LAMBERT ST
Mailing Address - Street 2:SUITE 222
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401
Mailing Address - Country:US
Mailing Address - Phone:540-886-3956
Mailing Address - Fax:540-886-3975
Practice Address - Street 1:40 LAMBERT ST
Practice Address - Street 2:SUITE 222
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401
Practice Address - Country:US
Practice Address - Phone:540-886-3956
Practice Address - Fax:540-886-3975
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904003575104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
11397930OtherCAQH