Healthcare Provider Details

I. General information

NPI: 1871420174
Provider Name (Legal Business Name): ROSE DEBERRY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 2ND ST
HAVRE MT
59501-3666
US

IV. Provider business mailing address

1107 CENTER DR
HAVRE MT
59501-4258
US

V. Phone/Fax

Practice location:
  • Phone: 406-390-4827
  • Fax:
Mailing address:
  • Phone: 406-481-6050
  • Fax: 406-420-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-88256
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: