Provider Demographics
NPI:1285057232
Name:AGNE, ROULA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ROULA
Middle Name:
Last Name:AGNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3236
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-3236
Mailing Address - Country:US
Mailing Address - Phone:406-531-2416
Mailing Address - Fax:855-201-3734
Practice Address - Street 1:415 N HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4557
Practice Address - Country:US
Practice Address - Phone:406-531-2416
Practice Address - Fax:855-201-3734
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT46421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1285057232Medicaid