Provider Demographics
NPI:1285286443
Name:LAX, ROBERT AILES
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:AILES
Last Name:LAX
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 1:246 S. CHESTNUT ST.
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266
Mailing Address - Country:US
Mailing Address - Phone:330-298-9391
Mailing Address - Fax:330-298-9392
Practice Address - Street 1:246 S. CHESTNUT ST.
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-298-9391
Practice Address - Fax:330-298-9392
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021208101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)