Provider Demographics
NPI:1063844215
Name:ROATH, MISTI KAY
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:KAY
Last Name:ROATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34718 CARPENTER LN
Mailing Address - Street 2:
Mailing Address - City:WISTER
Mailing Address - State:OK
Mailing Address - Zip Code:74966-2577
Mailing Address - Country:US
Mailing Address - Phone:918-839-0751
Mailing Address - Fax:
Practice Address - Street 1:34718 CARPENTER LN
Practice Address - Street 2:
Practice Address - City:WISTER
Practice Address - State:OK
Practice Address - Zip Code:74966-2577
Practice Address - Country:US
Practice Address - Phone:918-839-0751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health