Provider Demographics
NPI:1083645873
Name:ROBERTS, KIMBERLEY (PMHCNS-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BOYNTON ST
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04631-1306
Mailing Address - Country:US
Mailing Address - Phone:207-255-3400
Mailing Address - Fax:207-255-3401
Practice Address - Street 1:53 FREMONT ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-1320
Practice Address - Country:US
Practice Address - Phone:207-255-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER028815364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME258550099Medicaid
ME201826Medicare Oscar/Certification