Provider Demographics
NPI:1063923506
Name:ROTH, ELIANA FARA
Entity type:Individual
Prefix:
First Name:ELIANA
Middle Name:FARA
Last Name:ROTH
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 1:5 CONSTITUTION WAY STE C
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CONSTITUTION WAY STE C
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1199
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency