Provider Demographics
NPI:1861701328
Name:ROTH, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-8636
Mailing Address - Country:US
Mailing Address - Phone:207-784-7738
Mailing Address - Fax:
Practice Address - Street 1:89 PARTRIDGE LN
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-8636
Practice Address - Country:US
Practice Address - Phone:207-784-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME31341103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling