Basic Information
| Provider Information | |||||||||
| NPI: | 1104377233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LICSWA, CDPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARKIN | ||||||||
| OtherFirstName: | CHEYENNE | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 E FOURTH PLAIN BLVD BLDG 17 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986613717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603978484 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 E FOURTH PLAIN BLVD BLDG 17 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603978484 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 60798899 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 60811714 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.