Provider Demographics
NPI:1598023731
Name:ROEDER, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:ROEDER
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 1:1312 WESTEN ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3352
Mailing Address - Country:US
Mailing Address - Phone:270-904-1072
Mailing Address - Fax:270-904-1073
Practice Address - Street 1:1312 WESTEN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3352
Practice Address - Country:US
Practice Address - Phone:270-904-1072
Practice Address - Fax:270-904-1073
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2550401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY255040OtherKENTUCKY SOCIAL WORK BOARD LCSW
KY7100679350Medicaid