Provider Demographics
NPI:1861032724
Name:ROTH, AMANDA COLLEEN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:COLLEEN
Last Name:ROTH
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 1:326 34TH ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9271
Mailing Address - Country:US
Mailing Address - Phone:307-751-5111
Mailing Address - Fax:
Practice Address - Street 1:956 12TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3602
Practice Address - Country:US
Practice Address - Phone:307-751-5111
Practice Address - Fax:307-587-4014
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-2124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional