Provider Demographics
NPI:1881370302
Name:ROTH, KELSEY MADISON
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MADISON
Last Name:ROTH
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 1:8509 145TH ST NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98329-8810
Mailing Address - Country:US
Mailing Address - Phone:360-296-4822
Mailing Address - Fax:
Practice Address - Street 1:8509 145TH ST NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98329-8810
Practice Address - Country:US
Practice Address - Phone:360-296-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61246264101YM0800X
WALH61502038101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health