MEDICARE: KELLI JEANNE ROARK LICSW, SUDP

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	CP60817555	WA
2	101YM0800X	Mental Health Counselor	LW60828872	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LW60828872	OTHER	WA	SOCIAL WORKER INDEPENDENT CLINICAL LICENSE
2	CP60817555	OTHER	WA	SUBSTANCE USE DISORDER PROFESSIONAL CERTIFICATION

General Provider Information

NPI Number	:	1568722445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI JEANNE ROARK LICSW, SUDP

Provider Business Mailing Address
First Line	:	4511 188TH ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-7778
Country	:	US
Telephone Number	:	425-231-7589
Fax Number	:	425-258-5275

Provider Business Practice Location Address
First Line	:	4511 188TH ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-7778
Country	:	US
Telephone Number	:	425-231-7589
Fax Number	:

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

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	03/24/2020

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