Provider Demographics
NPI:1558841684
Name:ROBERTS, KEVIN D
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FIRST STREET APT 5
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084
Mailing Address - Country:US
Mailing Address - Phone:904-293-6757
Mailing Address - Fax:
Practice Address - Street 1:20 FIRST STREET APT 5
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-293-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service