Provider Demographics
NPI:1538728480
Name:ROTH, BRIAN SCOTT
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:POLLOCK PINES
Mailing Address - State:CA
Mailing Address - Zip Code:95726-8829
Mailing Address - Country:US
Mailing Address - Phone:530-554-7401
Mailing Address - Fax:
Practice Address - Street 1:3336 BRADSHAW RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2615
Practice Address - Country:US
Practice Address - Phone:916-300-6576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist