Provider Demographics
NPI:1992580823
Name:ROTH THERAPEUTIC SERVICES PLLC
Entity type:Organization
Organization Name:ROTH THERAPEUTIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:419-202-3350
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:LAKE JUNALUSKA
Mailing Address - State:NC
Mailing Address - Zip Code:28745-0712
Mailing Address - Country:US
Mailing Address - Phone:419-202-3350
Mailing Address - Fax:
Practice Address - Street 1:545 N LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE JUNALUSKA
Practice Address - State:NC
Practice Address - Zip Code:28745-9742
Practice Address - Country:US
Practice Address - Phone:419-202-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health