Provider Demographics
NPI:1871981423
Name:ROBERTS, STACY RENEE
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:RENEE
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 1:416 ATTICA ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1810
Mailing Address - Country:US
Mailing Address - Phone:937-492-9982
Mailing Address - Fax:937-492-6420
Practice Address - Street 1:2040 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-9004
Practice Address - Country:US
Practice Address - Phone:937-492-9982
Practice Address - Fax:937-492-6420
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA01862231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist