MEDICARE: ROBERTA RIDYN KELLEY LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	305002	MN
2	106H00000X	Marriage & Family Therapist	4461	MN

General Provider Information

NPI Number	:	1538831987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTA RIDYN KELLEY LMFT

Provider Business Mailing Address
First Line	:	4800 N SCOTTSDALE RD STE 2500
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-7630
Country	:	US
Telephone Number	:	612-915-0049
Fax Number	:

Provider Business Practice Location Address
First Line	:	3007 HARBOR LN N STE 1600
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-5142
Country	:	US
Telephone Number	:	612-915-0049
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2021
Last Update Date	:	06/12/2025

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