Provider Demographics
NPI:1891379509
Name:JULIE ROTH, PLLC
Entity type:Organization
Organization Name:JULIE ROTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-585-6061
Mailing Address - Street 1:147 MAPLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1121
Mailing Address - Country:US
Mailing Address - Phone:309-712-6396
Mailing Address - Fax:
Practice Address - Street 1:208 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2044
Practice Address - Country:US
Practice Address - Phone:309-585-6061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-09
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health