Provider Demographics
NPI:1538052048
Name:ROTH, PHILIP (LPC)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12002 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 MARKET LOOP STE 3
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-2185
Practice Address - Country:US
Practice Address - Phone:815-477-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional