Provider Demographics
NPI:1184152498
Name:ROUDABUSH-PATEL, KELLY ELIZABETH
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:ROUDABUSH-PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:ROUDABUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:856 W COOK RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-5012
Mailing Address - Country:US
Mailing Address - Phone:614-563-7975
Mailing Address - Fax:
Practice Address - Street 1:856 W COOK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-5012
Practice Address - Country:US
Practice Address - Phone:419-525-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20790757103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2887587Medicaid