Provider Demographics
NPI:1649828641
Name:DEROCHE, MARY LOUISE (LAC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:DEROCHE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417-0450
Mailing Address - Country:US
Mailing Address - Phone:406-338-6330
Mailing Address - Fax:
Practice Address - Street 1:807 NORTH PIEGAN STREET
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT786101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1285854885Medicaid