Provider Demographics
NPI:1063764587
Name:ROTH CLINIC (DBA)
Entity type:Organization
Organization Name:ROTH CLINIC (DBA)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIA
Authorized Official - Middle Name:ANGELICA
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-227-0124
Mailing Address - Street 1:734 W PORT PLZ DR.
Mailing Address - Street 2:SUITE 273
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3000
Mailing Address - Country:US
Mailing Address - Phone:314-227-0124
Mailing Address - Fax:
Practice Address - Street 1:734 W PORT PLZ DR.
Practice Address - Street 2:SUITE 273
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3000
Practice Address - Country:US
Practice Address - Phone:314-227-0124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030440251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1306164728OtherMEDICARE NPI TYPE 1
MOMA2277OtherMEDICARE PTAN
MO12086529OtherCAQH