Basic Information
Provider Information | |||||||||
NPI: | 1942925524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTH | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LLBSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARTH | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11686 PATTERSON LAKE DR | ||||||||
Address2: |   | ||||||||
City: | PINCKNEY | ||||||||
State: | MI | ||||||||
PostalCode: | 48169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348450933 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2280 E GRAND RIVER AVE | ||||||||
Address2: |   | ||||||||
City: | HOWELL | ||||||||
State: | MI | ||||||||
PostalCode: | 488438503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5175464126 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2022 | ||||||||
LastUpdateDate: | 10/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.