Provider Demographics
NPI:1902927809
Name:ROBERTS, KATHY L (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 HOSPITAL ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5312
Mailing Address - Country:US
Mailing Address - Phone:228-696-9224
Mailing Address - Fax:228-696-9228
Practice Address - Street 1:15012 LEMOYNE BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-5205
Practice Address - Country:US
Practice Address - Phone:228-396-8460
Practice Address - Fax:228-396-1141
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC26921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07703301Medicaid
MSC2692OtherLCSW LICENSE