Provider Demographics
NPI:1528570371
Name:ROOS, REGINA MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MICHELLE
Last Name:ROOS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:MICHELLE
Other - Last Name:WHITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2508 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2016 N MERRILL AVE
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2062
Practice Address - Country:US
Practice Address - Phone:406-377-6075
Practice Address - Fax:406-377-6074
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3359101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3359OtherLAC LIC