Healthcare Provider Details

I. General information

NPI: 1336311174
Provider Name (Legal Business Name): LAHOMA T ROEBUCK MSW,LCSW,LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 W MAIN
ANTLERS OK
74523-1322
US

IV. Provider business mailing address

1322 W. MAIN
ANTLERS OK
74523-1322
US

V. Phone/Fax

Practice location:
  • Phone: 580-298-5062
  • Fax: 580-298-9958
Mailing address:
  • Phone: 580-298-5062
  • Fax: 580-298-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3668
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11196
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: