Provider Demographics
NPI:1124289640
Name:ROTH, GARY L (OTR)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:ROTH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KILLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05751-9476
Mailing Address - Country:US
Mailing Address - Phone:802-773-4943
Mailing Address - Fax:
Practice Address - Street 1:143 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:KILLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05751-9476
Practice Address - Country:US
Practice Address - Phone:802-773-4943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0720000081225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation