Provider Demographics
NPI:1306164728
Name:ROTH, LIA ANGELICA (PSYA D)
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:ANGELICA
Last Name:ROTH
Suffix:
Gender:F
Credentials:PSYA D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 NEWKIRK CIR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6720
Mailing Address - Country:US
Mailing Address - Phone:314-714-5227
Mailing Address - Fax:
Practice Address - Street 1:440 NEWKIRK CIR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6720
Practice Address - Country:US
Practice Address - Phone:314-714-5227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090304401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740512854OtherNPI 2