Basic Information
| Provider Information | |||||||||
| NPI: | 1194149575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | KERRIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7565 GRANGER RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441254818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164479600 | ||||||||
| FaxNumber: | 2164479603 | ||||||||
| Practice Location | |||||||||
| Address1: | 7565 GRANGER RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441254818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164479600 | ||||||||
| FaxNumber: | 2164479603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2014 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S1303005 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.