Basic Information
| Provider Information | |||||||||
| NPI: | 1568722445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROARK | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | LICSW, SUDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4511 188TH ST NE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982237778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252317589 | ||||||||
| FaxNumber: | 4252585275 | ||||||||
| Practice Location | |||||||||
| Address1: | 4511 188TH ST NE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982237778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252317589 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60817555 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LW60828872 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | LW60828872 | 01 | WA | SOCIAL WORKER INDEPENDENT CLINICAL LICENSE | OTHER | CP60817555 | 01 | WA | SUBSTANCE USE DISORDER PROFESSIONAL CERTIFICATION | OTHER |