Provider Demographics
NPI:1033300017
Name:ROTH, MARY ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E12155 SIDE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9752
Mailing Address - Country:US
Mailing Address - Phone:608-209-4480
Mailing Address - Fax:608-355-0527
Practice Address - Street 1:E12155 SIDE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9752
Practice Address - Country:US
Practice Address - Phone:608-209-4480
Practice Address - Fax:608-355-0527
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional