Provider Demographics
NPI:1174697320
Name:ROBERTS, KIMBERLY MICHELLE (PSYD, LPC, CCM)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PSYD, LPC, CCM
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:455 HUENERS LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9195
Mailing Address - Country:US
Mailing Address - Phone:615-668-6775
Mailing Address - Fax:
Practice Address - Street 1:455 HUENERS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9195
Practice Address - Country:US
Practice Address - Phone:615-668-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional