Provider Demographics
NPI:1750151346
Name:ROPER, KELLY L
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:ROPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 BIG HORN TRL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2483
Mailing Address - Country:US
Mailing Address - Phone:405-210-6683
Mailing Address - Fax:405-251-8538
Practice Address - Street 1:1586 S 21ST ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4282
Practice Address - Country:US
Practice Address - Phone:405-210-6683
Practice Address - Fax:405-251-8538
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSWC.0000001363104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker