Provider Demographics
NPI:1366841801
Name:KIRSHBAUM-GROCK, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KIRSHBAUM-GROCK
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:PO BOX 13092
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89507-3092
Mailing Address - Country:US
Mailing Address - Phone:775-348-4900
Mailing Address - Fax:
Practice Address - Street 1:527 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-1603
Practice Address - Country:US
Practice Address - Phone:775-348-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01517-L101YA0400X
NVMI0446106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)