Healthcare Provider Details

I. General information

NPI: 1285642413
Provider Name (Legal Business Name): MARK MORGAN ROEBUCK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 LAMBERT ST SUITE 222
STAUNTON VA
24401
US

IV. Provider business mailing address

40 LAMBERT ST SUITE 222
STAUNTON VA
24401
US

V. Phone/Fax

Practice location:
  • Phone: 540-886-3956
  • Fax: 540-886-3975
Mailing address:
  • Phone: 540-886-3956
  • Fax: 540-886-3975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904003575
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: