Provider Demographics
NPI:1588156616
Name:ROOT, KELSIE BRIANNE
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:BRIANNE
Last Name:ROOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:BRIANNE
Other - Last Name:PAXMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1195 SELMI DR UNIT H301
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-7721
Mailing Address - Country:US
Mailing Address - Phone:435-525-3953
Mailing Address - Fax:
Practice Address - Street 1:9535 OAKLEY LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-6101
Practice Address - Country:US
Practice Address - Phone:775-843-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103K00000X
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst