Provider Demographics
NPI:1801157805
Name:ROBERTS, KENNETH JAMES JR (LMT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:ROBERTS
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9420 TOWNE SQUARE AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6922
Mailing Address - Country:US
Mailing Address - Phone:812-989-2489
Mailing Address - Fax:
Practice Address - Street 1:9420 TOWNE SQUARE AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6922
Practice Address - Country:US
Practice Address - Phone:812-989-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020162225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist