MEDICARE: MS. MARY KATHLEEN ROBINSON-BLACK L.P.C.

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	101Y00000X	Counselor	2001007821	MO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	2001007821	MO
3	101YM0800X	Mental Health Counselor	2001007821	MO
4	101YP2500X	Professional Counselor	2001007821	MO

General Provider Information

NPI Number	:	1174846075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHLEEN ROBINSON-BLACK L.P.C.

Provider Business Mailing Address
First Line	:	1003 HAUCK DR
Second Line	:
City	:	ROLLA
State	:	MO
Zip	:	65401-2584
Country	:	US
Telephone Number	:	573-368-7302
Fax Number	:	573-368-7300

Provider Business Practice Location Address
First Line	:	1003 HAUCK DR
Second Line	:
City	:	ROLLA
State	:	MO
Zip	:	65401-2584
Country	:	US
Telephone Number	:	573-368-7302
Fax Number	:	573-368-7300

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

Provider Enumeration Date	:	03/05/2010
Last Update Date	:	03/05/2010

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