Provider Demographics
NPI:1770545543
Name:SUTAK, ROBERT WAYNE (LISW-S)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WAYNE
Last Name:SUTAK
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10391 MIDWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44442
Mailing Address - Country:US
Mailing Address - Phone:330-501-9319
Mailing Address - Fax:330-366-0312
Practice Address - Street 1:10391 MIDWAY DRIVE
Practice Address - Street 2:
Practice Address - City:NEW MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:44442
Practice Address - Country:US
Practice Address - Phone:330-501-9319
Practice Address - Fax:330-366-0312
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0009404101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSUSW26281Medicare ID - Type Unspecified