Provider Demographics
NPI:1548821085
Name:ROTH, STEVEN TIMOTHY (LMT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:TIMOTHY
Last Name:ROTH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 LARRY AVE N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-5520
Mailing Address - Country:US
Mailing Address - Phone:503-851-2868
Mailing Address - Fax:
Practice Address - Street 1:3990 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4888
Practice Address - Country:US
Practice Address - Phone:503-364-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25121225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist