Provider Demographics
NPI:1366564536
Name:ROTH, CARLA J (CADC, CADAC IV, LCAC)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:J
Last Name:ROTH
Suffix:
Gender:F
Credentials:CADC, CADAC IV, LCAC
Other - Prefix:MS
Other - First Name:CARLA
Other - Middle Name:S
Other - Last Name:DAYVAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC, CADAC IV
Mailing Address - Street 1:100 W COURT AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3502
Mailing Address - Country:US
Mailing Address - Phone:812-207-8633
Mailing Address - Fax:
Practice Address - Street 1:100 W COURT AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3502
Practice Address - Country:US
Practice Address - Phone:812-207-8633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000608A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)