Provider Demographics
NPI:1356093678
Name:ROBERTS, KRYSTAL (LCSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:7721 PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4319
Mailing Address - Country:US
Mailing Address - Phone:262-383-5420
Mailing Address - Fax:
Practice Address - Street 1:6121 GREEN BAY RD STE 200
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2931
Practice Address - Country:US
Practice Address - Phone:262-864-1141
Practice Address - Fax:262-351-0132
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9838-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100215279Medicaid