Provider Demographics
NPI:1285093237
Name:ROTH, LAURIE JOANNE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JOANNE
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 1:9507 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1248
Mailing Address - Country:US
Mailing Address - Phone:509-466-6632
Mailing Address - Fax:
Practice Address - Street 1:9507 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1248
Practice Address - Country:US
Practice Address - Phone:509-466-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health