Provider Demographics
NPI:1285877282
Name:ROTH, DIANNE PATRICIA (MACCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:PATRICIA
Last Name:ROTH
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63780-1111
Mailing Address - Country:US
Mailing Address - Phone:573-264-2131
Mailing Address - Fax:
Practice Address - Street 1:3000 MAIN ST
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:MO
Practice Address - Zip Code:63780-1111
Practice Address - Country:US
Practice Address - Phone:573-264-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist