Provider Demographics
NPI:1316728199
Name:ROTH, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:7500 BERRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43571-9336
Mailing Address - Country:US
Mailing Address - Phone:419-944-6566
Mailing Address - Fax:
Practice Address - Street 1:3529 RIVERS EDGE DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1672
Practice Address - Country:US
Practice Address - Phone:419-874-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003994225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist