Basic Information
| Provider Information | |||||||||
| NPI: | 1477603827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARVEY | ||||||||
| OtherFirstName: | NATALIE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 398 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287795196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Practice Location | |||||||||
| Address1: | 98D COPE CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287799508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2005-92 | KY | N | Behavioral Health & Social Service Providers | Psychologist | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 30615058 | 05 | KY | MEDICAID |