Provider Demographics
NPI:1316290372
Name:ROTH, KATHERINE MARGARET (LCSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARGARET
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W KENNEDY BLVD
Mailing Address - Street 2:SUITE 326
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2288
Mailing Address - Country:US
Mailing Address - Phone:248-761-3284
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:SUITE 326
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2288
Practice Address - Country:US
Practice Address - Phone:248-761-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW132871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical