Provider Demographics
NPI:1912450909
Name:RODDY, CAROL (CSAC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RODDY
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:HORWATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC
Mailing Address - Street 1:108 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2110
Mailing Address - Country:US
Mailing Address - Phone:920-887-9549
Mailing Address - Fax:920-887-3977
Practice Address - Street 1:108 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2110
Practice Address - Country:US
Practice Address - Phone:920-887-9549
Practice Address - Fax:920-887-3977
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11055 - 132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)