Provider Demographics
NPI:1730740366
Name:ROBERTS, NIKOLE K (PHD, LP)
Entity type:Individual
Prefix:
First Name:NIKOLE
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NIKOLE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5065
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:417-761-5065
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019037970103TC0700X, 103TC0700X
0000171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14491942OtherCAQH
MO490075997Medicaid