Provider Demographics
NPI:1720284615
Name:ROTH, MARGARET S (MSED)
Entity type:Individual
Prefix:MRS
First Name:MARGARET
Middle Name:S
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 TINKERHILL RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-7603
Mailing Address - Country:US
Mailing Address - Phone:610-935-7393
Mailing Address - Fax:
Practice Address - Street 1:4025 CHESTNUT ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3054
Practice Address - Country:US
Practice Address - Phone:215-382-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000049106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMF000049OtherMFT LICENSE NUMBER
PA27093OtherAAMFT IDENTIFICATION NUMB