Provider Demographics
NPI:1932935095
Name:ROTH, MAKALA ANNE
Entity type:Individual
Prefix:
First Name:MAKALA
Middle Name:ANNE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 BURWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-3368
Mailing Address - Country:US
Mailing Address - Phone:817-403-4001
Mailing Address - Fax:
Practice Address - Street 1:773 BANDIT TRL
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-0111
Practice Address - Country:US
Practice Address - Phone:817-984-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician