Provider Demographics
NPI:1154730216
Name:GRONLUND-ROBERTS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRONLUND-ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-3432
Mailing Address - Country:US
Mailing Address - Phone:707-464-4349
Mailing Address - Fax:
Practice Address - Street 1:900 FERNDALE LN
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8061
Practice Address - Country:US
Practice Address - Phone:707-218-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-03
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health