Provider Demographics
NPI:1720350721
Name:ROTH, ALEXANDRA C (PT)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:C
Last Name:ROTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 GREEN PARK RD
Mailing Address - Street 2:REHAB DEPT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7211
Mailing Address - Country:US
Mailing Address - Phone:314-845-0900
Mailing Address - Fax:
Practice Address - Street 1:9350 GREEN PARK RD
Practice Address - Street 2:REHAB DEPT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7211
Practice Address - Country:US
Practice Address - Phone:314-845-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist