Provider Demographics
NPI:1679090534
Name:ROBERTS, KELLY (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5734 HOME RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-3233
Mailing Address - Country:US
Mailing Address - Phone:814-812-5491
Mailing Address - Fax:
Practice Address - Street 1:2520 HAMPTON RD STE 18
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2073
Practice Address - Country:US
Practice Address - Phone:814-812-5491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW01965141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical