Provider Demographics
NPI:1336521947
Name:ROBERTSON, KEVIN (PLPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2127
Mailing Address - Country:US
Mailing Address - Phone:660-562-3000
Mailing Address - Fax:660-562-3002
Practice Address - Street 1:318 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-1644
Practice Address - Country:US
Practice Address - Phone:660-562-3000
Practice Address - Fax:660-562-3002
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5019251006101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)