Provider Demographics
NPI:1740503556
Name:ROBERTS, KENNETH LEWIS (LADC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEWIS
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 PRIOR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5165
Mailing Address - Country:US
Mailing Address - Phone:651-644-1304
Mailing Address - Fax:
Practice Address - Street 1:366 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5165
Practice Address - Country:US
Practice Address - Phone:651-644-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302801101YA0400X
MN1590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)