Provider Demographics
NPI:1295390532
Name:LAUBE, MATTHEW JEROME
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JEROME
Last Name:LAUBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-9158
Mailing Address - Country:US
Mailing Address - Phone:937-444-6127
Mailing Address - Fax:937-444-6192
Practice Address - Street 1:116 N HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-9158
Practice Address - Country:US
Practice Address - Phone:937-444-6127
Practice Address - Fax:937-444-6192
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOCPSA161406405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional