Provider Demographics
NPI:1104044890
Name:ROSE, KELLY PATRICK
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:PATRICK
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 LARAMIE BLVD UNIT H
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4782
Mailing Address - Country:US
Mailing Address - Phone:303-246-0487
Mailing Address - Fax:
Practice Address - Street 1:1333 IRIS AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2226
Practice Address - Country:US
Practice Address - Phone:303-413-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health