Provider Demographics
NPI:1568483725
Name:ROOT, MARLA M (LMHP/CPC)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:M
Last Name:ROOT
Suffix:
Gender:F
Credentials:LMHP/CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 D ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-2318
Mailing Address - Country:US
Mailing Address - Phone:402-729-6979
Mailing Address - Fax:402-729-4094
Practice Address - Street 1:510 D ST
Practice Address - Street 2:SUITE 2
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-2318
Practice Address - Country:US
Practice Address - Phone:402-729-6979
Practice Address - Fax:402-729-4094
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2918101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1002497100Medicaid