Provider Demographics
NPI:1669197174
Name:ROBERTS, AUSTIN GAGE
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:GAGE
Last Name:ROBERTS
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:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-0464
Mailing Address - Country:US
Mailing Address - Phone:330-303-9741
Mailing Address - Fax:330-424-7876
Practice Address - Street 1:964 N MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9363
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:330-424-7876
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator