Healthcare Provider Details

I. General information

NPI: 1184152498
Provider Name (Legal Business Name): KELLY ELIZABETH ROUDABUSH-PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELIZABETH ROUDABUSH ED.S.

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 W COOK RD
MANSFIELD OH
44907-5012
US

IV. Provider business mailing address

856 W COOK RD
MANSFIELD OH
44907-5012
US

V. Phone/Fax

Practice location:
  • Phone: 419-525-6400
  • Fax:
Mailing address:
  • Phone: 614-563-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number20790757
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: