MEDICARE: KELLY RENEE ROBERSON MA, LCMHCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	A19095	NC

General Provider Information

NPI Number	:	1730802273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RENEE ROBERSON MA, LCMHCA

Provider Business Mailing Address
First Line	:	2813 COLTSGATE RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3585
Country	:	US
Telephone Number	:	704-362-3123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2813 COLTSGATE RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3585
Country	:	US
Telephone Number	:	704-362-3123
Fax Number	:	704-943-7272

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2022
Last Update Date	:	08/08/2023

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