Provider Demographics
NPI:1750415873
Name:ROLLER, KYLEE J (PHD)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:J
Last Name:ROLLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16771 15TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ND
Mailing Address - Zip Code:58218-9239
Mailing Address - Country:US
Mailing Address - Phone:701-792-6488
Mailing Address - Fax:701-335-7100
Practice Address - Street 1:16771 15TH ST NE
Practice Address - Street 2:
Practice Address - City:BUXTON
Practice Address - State:ND
Practice Address - Zip Code:58218-9239
Practice Address - Country:US
Practice Address - Phone:701-792-6488
Practice Address - Fax:701-335-7100
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054519Medicaid