Provider Demographics
NPI:1366583080
Name:ROTH, LAURA A (OTR)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DOWNING AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-2014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4022
Practice Address - Country:US
Practice Address - Phone:516-921-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005725251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health