Healthcare Provider Details

I. General information

NPI: 1558841684
Provider Name (Legal Business Name): MR. KEVIN D ROBERTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 FIRST STREET APT 5
ST. AUGUSTINE FL
32084
US

IV. Provider business mailing address

20 FIRST STREET APT 5
ST. AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-293-6757
  • Fax:
Mailing address:
  • Phone: 904-293-6757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: