Provider Demographics
NPI:1306820824
Name:ROLLER, REBECCA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:ROLLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E HEWITT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65661-1138
Mailing Address - Country:US
Mailing Address - Phone:417-637-1476
Mailing Address - Fax:866-520-5586
Practice Address - Street 1:310 E HEWITT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GREENFIELD
Practice Address - State:MO
Practice Address - Zip Code:65661-1138
Practice Address - Country:US
Practice Address - Phone:417-637-1476
Practice Address - Fax:866-520-5586
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004037100101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497227124Medicaid