Provider Demographics
NPI:1942925524
Name:ROTH, KELLY LEE (LLBSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEE
Last Name:ROTH
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:BARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11686 PATTERSON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169
Mailing Address - Country:US
Mailing Address - Phone:734-845-0933
Mailing Address - Fax:
Practice Address - Street 1:2280 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8503
Practice Address - Country:US
Practice Address - Phone:517-546-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor