Provider Demographics
NPI:1700139755
Name:SAC RIVER INSTITUTE
Entity Type:Organization
Organization Name:SAC RIVER INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-777-1476
Mailing Address - Street 1:928 E DADE 68
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65635-8112
Mailing Address - Country:US
Mailing Address - Phone:417-777-1476
Mailing Address - Fax:866-520-5586
Practice Address - Street 1:131 ELM STREET
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:MO
Practice Address - Zip Code:65635
Practice Address - Country:US
Practice Address - Phone:417-995-2476
Practice Address - Fax:866-520-5586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006033497103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty