Provider Demographics
NPI:1780023572
Name:ROTH, CARRIE (MA, LAC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0122
Mailing Address - Country:US
Mailing Address - Phone:406-248-3175
Mailing Address - Fax:406-248-3821
Practice Address - Street 1:1231 N 29TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0122
Practice Address - Country:US
Practice Address - Phone:406-248-3175
Practice Address - Fax:406-248-3821
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)