Provider Demographics
NPI:1578803284
Name:ROTH, ERIK G (LCSW)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:G
Last Name:ROTH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10096 W FAIRVIEW AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10096 W FAIRVIEW AVE STE 160
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5004
Practice Address - Country:US
Practice Address - Phone:208-908-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-427531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical