Provider Demographics
NPI:1184668055
Name:ROBERTS, KATHLEEN E (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
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 1:700 WEST AVENUE SOUTH
Mailing Address - Street 2:ATTN PHYSICIAN SERVICES
Mailing Address - City:LACROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:700 WEST AVENUE SOUTH
Practice Address - Street 2:ATTN PHYSICIAN SERVICES
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39596500Medicaid
Q01805Medicare UPIN
WI39596500Medicaid