Provider Demographics
NPI:1609572437
Name:ROTH, TAMMIE (LADC)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:
Other - Last Name:SCHLAHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:703 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 E FRANKLIN AVE STE 200A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2395
Practice Address - Country:US
Practice Address - Phone:651-300-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305286101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)