Provider Demographics
NPI:1760491609
Name:ROE, KELLI ANN (BA)
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:ANN
Last Name:ROE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8014 SUNFIELD CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-1528
Mailing Address - Country:US
Mailing Address - Phone:317-621-2099
Mailing Address - Fax:
Practice Address - Street 1:1500 N RITTER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3027
Practice Address - Country:US
Practice Address - Phone:317-621-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN8734Medicaid