Provider Demographics
NPI:1295448256
Name:AMANDA ROTH, LLC
Entity type:Organization
Organization Name:AMANDA ROTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:307-751-5111
Mailing Address - Street 1:956 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3602
Mailing Address - Country:US
Mailing Address - Phone:307-751-5111
Mailing Address - Fax:307-587-4014
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLPC-2124OtherMENTAL HEALTH PROFESSIONALS LICENSING BOARD