Provider Demographics
NPI:1659812493
Name:ROBERTS, KIMBERLY ANN (IECE)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5259 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:MAYSLICK
Mailing Address - State:KY
Mailing Address - Zip Code:41055-8999
Mailing Address - Country:US
Mailing Address - Phone:606-584-7224
Mailing Address - Fax:
Practice Address - Street 1:5259 WEAVER RD
Practice Address - Street 2:
Practice Address - City:MAYSLICK
Practice Address - State:KY
Practice Address - Zip Code:41055-8999
Practice Address - Country:US
Practice Address - Phone:606-584-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200129228222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist