Provider Demographics
NPI:1164315214
Name:ROTH, MEAGAN (LAC)
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SALMON ST
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-3436
Mailing Address - Country:US
Mailing Address - Phone:732-575-4132
Mailing Address - Fax:732-575-4132
Practice Address - Street 1:2 INDUSTRIAL WAY W STE 203
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2266
Practice Address - Country:US
Practice Address - Phone:848-444-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00692800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health