Provider Demographics
NPI:1831265370
Name:ROLLINS, KATHERINE SUSANNE (PSYD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUSANNE
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 OLD WINSTON RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8780
Mailing Address - Country:US
Mailing Address - Phone:336-992-2171
Mailing Address - Fax:
Practice Address - Street 1:851 OLD WINSTON RD
Practice Address - Street 2:SUITE 107
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8780
Practice Address - Country:US
Practice Address - Phone:336-992-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2901103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000919Medicaid
NC2901OtherPSYCHOLOGY BOARD LICENSE
NC2901OtherPSYCHOLOGY BOARD LICENSE
NC6000919Medicaid