Provider Demographics
NPI:1366736688
Name:ROEDER, ALICIA BLAIR (MS)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:BLAIR
Last Name:ROEDER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 DEVERON DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-1022
Mailing Address - Country:US
Mailing Address - Phone:712-309-1594
Mailing Address - Fax:
Practice Address - Street 1:1070 DEVERON DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-1022
Practice Address - Country:US
Practice Address - Phone:712-309-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9223101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor