Healthcare Provider Details

I. General information

NPI: 1629692868
Provider Name (Legal Business Name): PATRICIA NICOLE ROTH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax: 605-742-3888
Mailing address:
  • Phone: 605-698-7606
  • Fax: 605-742-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15061692
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: