Provider Demographics
NPI:1649787805
Name:ROOT, KELLY ANNE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:ROOT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3043
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89450-3043
Mailing Address - Country:US
Mailing Address - Phone:530-417-2466
Mailing Address - Fax:530-417-2466
Practice Address - Street 1:770 NORTHWOOD BLVD STE 6
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-8234
Practice Address - Country:US
Practice Address - Phone:775-832-0952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist