Provider Demographics
NPI:1255038287
Name:CARBONELL, RODRICK JULIUS
Entity type:Individual
Prefix:
First Name:RODRICK
Middle Name:JULIUS
Last Name:CARBONELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 N LAST CHANCE GULCH
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-0700
Mailing Address - Country:US
Mailing Address - Phone:406-594-6972
Mailing Address - Fax:406-513-1055
Practice Address - Street 1:1824 N LAST CHANCE GULCH
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-0700
Practice Address - Country:US
Practice Address - Phone:406-594-6972
Practice Address - Fax:406-513-1055
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT62373101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)