Provider Demographics
NPI:1619029949
Name:ROBERTS, MARK (LCP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7840 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-2152
Mailing Address - Country:US
Mailing Address - Phone:913-328-4600
Mailing Address - Fax:
Practice Address - Street 1:7840 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2152
Practice Address - Country:US
Practice Address - Phone:913-328-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCP 061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3620000Medicare ID - Type Unspecified