Basic Information
| Provider Information | |||||||||
| NPI: | 1194891994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 CAMELOT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
| FaxNumber: | 9209078209 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 CAMELOT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
| FaxNumber: | 9209078209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 672 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 3105 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 3105-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 672-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 39307400 | 05 | WI | MEDICAID |