Provider Demographics
NPI:1568771681
Name:ROBERTS, KIMBERLY ANN (MA,LLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA,LLP
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA,LLP
Mailing Address - Street 1:23625 ROCKFORD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1624
Mailing Address - Country:US
Mailing Address - Phone:313-561-8947
Mailing Address - Fax:
Practice Address - Street 1:22995 HALL RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1539
Practice Address - Country:US
Practice Address - Phone:734-671-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010373103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent