Healthcare Provider Details

I. General information

NPI: 1386309383
Provider Name (Legal Business Name): KELLYN ROIKO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 VOYAGER CV
KYLE TX
78640-6417
US

IV. Provider business mailing address

304 VOYAGER CV
KYLE TX
78640-6417
US

V. Phone/Fax

Practice location:
  • Phone: 719-291-6099
  • Fax:
Mailing address:
  • Phone: 719-291-6099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106653
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09929750
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123275
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: