Provider Demographics
NPI:1114758364
Name:ROBERTS, LAUREN SOPHIA
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:SOPHIA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CENTER PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8859
Mailing Address - Country:US
Mailing Address - Phone:904-318-6109
Mailing Address - Fax:
Practice Address - Street 1:180 CENTER PLACE WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8859
Practice Address - Country:US
Practice Address - Phone:904-318-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician