Provider Demographics
NPI:1104377233
Name:KELLY, ROSE (LICSW)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CHEYENNE
Other - Middle Name:ROSE
Other - Last Name:LARKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD BLDG 17
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3717
Practice Address - Country:US
Practice Address - Phone:360-558-5795
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA608117141041C0700X, 1041C0700X
WASC60812048101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical