Provider Demographics
NPI:1326485756
Name:ROBERTS, KATHRYN MAYER (EDS, NCSP, LPES)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MAYER
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:EDS, NCSP, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CAHOUN STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401
Mailing Address - Country:US
Mailing Address - Phone:843-852-6524
Mailing Address - Fax:
Practice Address - Street 1:75 CAHOUN STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401
Practice Address - Country:US
Practice Address - Phone:843-852-6524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4554103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1588615918Medicaid