Provider Demographics
NPI:1699250084
Name:GROTH, ROBERTA ANN (LMT)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANN
Last Name:GROTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W IOWA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2826
Mailing Address - Country:US
Mailing Address - Phone:208-870-6658
Mailing Address - Fax:
Practice Address - Street 1:430 W IOWA AVE STE A
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2826
Practice Address - Country:US
Practice Address - Phone:208-870-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMASG-1782OtherIDAHO BUREAU OF OCCUPATIONAL LICENSES