Provider Demographics
NPI:1336753755
Name:ROBERTS, LAUREL E MAGNESS
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:E MAGNESS
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 1:524 GREENFIELD LN
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-1307
Mailing Address - Country:US
Mailing Address - Phone:385-354-1121
Mailing Address - Fax:
Practice Address - Street 1:3515 WERK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-6229
Practice Address - Country:US
Practice Address - Phone:385-354-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT476093Medicaid