Provider Demographics
NPI:1689715906
Name:WENDEROTH, ROBERTA (BOBBIE) JEANNE (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:ROBERTA (BOBBIE)
Middle Name:JEANNE
Last Name:WENDEROTH
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-6310
Mailing Address - Country:US
Mailing Address - Phone:406-207-3342
Mailing Address - Fax:406-721-3394
Practice Address - Street 1:1048 BURLINGTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5683
Practice Address - Country:US
Practice Address - Phone:406-207-3342
Practice Address - Fax:406-721-3394
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1276-LCPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT743580OtherBLUECROSS BLUESHIELD OF M
MT0033761Medicaid