Basic Information
| Provider Information | |||||||||
| NPI: | 1902927809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4105 HOSPITAL ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2286969224 | ||||||||
| FaxNumber: | 2286969228 | ||||||||
| Practice Location | |||||||||
| Address1: | 15012 LEMOYNE BLVD | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395325205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283968460 | ||||||||
| FaxNumber: | 2283961141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C2692 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 07703301 | 05 | MS | MEDICAID | C2692 | 01 | MS | LCSW LICENSE | OTHER |