Provider Demographics
NPI:1891168373
Name:ROBERTS, KIM LAND (LPC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LAND
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 BALDWIN FARMS DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-1555
Mailing Address - Country:US
Mailing Address - Phone:770-355-2381
Mailing Address - Fax:
Practice Address - Street 1:1511 JOHNSON FERRY RD STE 125
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6403
Practice Address - Country:US
Practice Address - Phone:770-703-9031
Practice Address - Fax:904-337-0329
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008144101YA0400X, 101YP2500X
FLTPMC2681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003170135CMedicaid
GA003170135FMedicaid
GA003170135AMedicaid