=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568771681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ANN ROBERTS MA,LLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2010
-----------------------------------------------------
Last Update Date | 10/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22995 HALL RD
-----------------------------------------------------
City | WOODHAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48183-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-671-3324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23625 ROCKFORD ST
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-561-8947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 6301010373
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------