Provider Demographics
NPI:1992593644
Name:ROTH, HALLIE (LCSW)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:ROTH
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 GOVERNOR DR UNIT 1118
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2522
Mailing Address - Country:US
Mailing Address - Phone:858-256-6068
Mailing Address - Fax:
Practice Address - Street 1:4079 GOVERNOR DR UNIT 1118
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2522
Practice Address - Country:US
Practice Address - Phone:858-256-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW227991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical