Provider Demographics
NPI:1336749563
Name:ROLLAND, KELLY JO (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:ROLLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 CYNTHIA DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-3742
Mailing Address - Country:US
Mailing Address - Phone:903-806-2738
Mailing Address - Fax:
Practice Address - Street 1:2904 4TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5124
Practice Address - Country:US
Practice Address - Phone:903-806-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX608561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical