Organization
ROTH CLINIC (DBA)
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LIA ANGELICA ROTH LCSW (PRESIDENT)
(314) 227-0124
Entity
Organization
Contact information
Practice address
734 W PORT PLZ DR., SUITE 273, SAINT LOUIS, MO 63146-3000
(314) 227-0124
Mailing address
734 W PORT PLZ DR., SUITE 273, SAINT LOUIS, MO 63146-3000
(314) 227-0124
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
2009030440
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12086529
CAQH
MO
01
—
1306164728
MEDICARE NPI TYPE 1
MO
01
—
MA2277
MEDICARE PTAN
MO
Enumeration date
10/08/2012
Last updated
10/08/2012
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