Provider Demographics
NPI:1396243622
Name:ROTH, ANNA (LPC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-1348
Mailing Address - Country:US
Mailing Address - Phone:913-353-8682
Mailing Address - Fax:
Practice Address - Street 1:115 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-1348
Practice Address - Country:US
Practice Address - Phone:913-353-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3207101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional