Provider Demographics
NPI:1568722445
Name:ROARK, KELLI JEANNE (LICSW, SUDP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JEANNE
Last Name:ROARK
Suffix:
Gender:F
Credentials:LICSW, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 188TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-7778
Mailing Address - Country:US
Mailing Address - Phone:425-231-7589
Mailing Address - Fax:425-258-5275
Practice Address - Street 1:4511 188TH ST NE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-7778
Practice Address - Country:US
Practice Address - Phone:425-231-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60817555101YA0400X
WALW60828872101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW60828872OtherSOCIAL WORKER INDEPENDENT CLINICAL LICENSE
WACP60817555OtherSUBSTANCE USE DISORDER PROFESSIONAL CERTIFICATION