Provider Demographics
NPI:1588147557
Name:ROTHE, CHERYL DIANE (MS, NCSP)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:DIANE
Last Name:ROTHE
Suffix:
Gender:F
Credentials:MS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3179
Mailing Address - Country:US
Mailing Address - Phone:209-331-7085
Mailing Address - Fax:
Practice Address - Street 1:3880 IRON CANYON CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-3612
Practice Address - Country:US
Practice Address - Phone:209-953-9437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool