Provider Demographics
NPI:1063411528
Name:ROTH, ALEXANDRA (LCSW)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:ROTH
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 1:8500 EXECUTIVE PARK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2225
Mailing Address - Country:US
Mailing Address - Phone:703-698-5220
Mailing Address - Fax:703-573-2351
Practice Address - Street 1:8500 EXECUTIVE PARK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2225
Practice Address - Country:US
Practice Address - Phone:703-698-5220
Practice Address - Fax:703-573-2351
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904003266104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
528410OtherNCPPO
DC0080OtherCAREFIRST DC
VA269409OtherANTHEM
7396420OtherAETNA
VA276677-000OtherMAGELLAN
4116181OtherMAMSI