Provider Demographics
NPI:1881875615
Name:ROBERTS, KRISTINE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRIS
Other - Middle Name:MARIE
Other - Last Name:CISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:326 BELINDA CT
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-6617
Mailing Address - Country:US
Mailing Address - Phone:757-879-2269
Mailing Address - Fax:
Practice Address - Street 1:1106 COLLEGE ST STE E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4021
Practice Address - Country:US
Practice Address - Phone:512-521-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-167691041C0700X
IL1490098151041C0700X
TX672951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical