Provider Demographics
NPI:1154585107
Name:ROTH, ERIC VAUGHN
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:VAUGHN
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 W. CECIL AVE.
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215
Mailing Address - Country:US
Mailing Address - Phone:661-721-2345
Mailing Address - Fax:661-721-6262
Practice Address - Street 1:2737 W. CECIL AVE.
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215
Practice Address - Country:US
Practice Address - Phone:661-721-2345
Practice Address - Fax:661-721-6262
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22498103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical