Provider Demographics
NPI:1902236219
Name:ROTH, AGNES (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:AGNES
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 REIFSNYDER RD
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-1523
Mailing Address - Country:US
Mailing Address - Phone:610-416-6061
Mailing Address - Fax:
Practice Address - Street 1:59 REIFSNYDER RD
Practice Address - Street 2:
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-1523
Practice Address - Country:US
Practice Address - Phone:610-416-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABACB229925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist