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1174697320 NPI number — KIMBERLY MICHELLE ROBERTS PSYD, LPC, CCM

NPI Number: 1174697320
Health Care Provider/Practitioner: KIMBERLY MICHELLE ROBERTS PSYD, LPC, CCM

Information about “1174697320” NPI (KIMBERLY MICHELLE ROBERTS PSYD, LPC, CCM) exists in 1174697320 in HTML format HTML  |  1174697320 in plain Text format TXT  |  1174697320 in PDF (Portable Document Format) PDF  |  1174697320 in an XML format XML  formats.

NPI Number : 1174697320 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1174697320",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "ROBERTS",
    "FirstName": "KIMBERLY",
    "MiddleName": "MICHELLE",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "PSYD, LPC, CCM",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "ROBERTS",
    "OtherFirstName": "KIMBERLY",
    "OtherMiddleName": "MICHELLE",
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": "5",
    "FirstLineMailingAddress": "455 HUENERS LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "JACKSONVILLE",
    "MailingAddressStateName": "OR",
    "MailingAddressPostalCode": "97530-9195",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "615-668-6775",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "455 HUENERS LN",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "JACKSONVILLE",
    "PracticeLocationAddressStateName": "OR",
    "PracticeLocationAddressPostalCode": "97530-9195",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "615-668-6775",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "11/20/2006",
    "LastUpdateDate": "05/13/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "101YP2500X",
        "TaxonomyName": "Professional Counselor",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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