Provider Demographics
NPI:1821860776
Name:ROSENBERG, KELSEY RYAN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:RYAN
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 WATT AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-2622
Mailing Address - Country:US
Mailing Address - Phone:916-344-0249
Mailing Address - Fax:
Practice Address - Street 1:3800 WATT AVE STE 110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2622
Practice Address - Country:US
Practice Address - Phone:916-344-0249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-PEHGCJ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist