Basic Information
| Provider Information | |||||||||
| NPI: | 1548340268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6420 SCULLY RD | ||||||||
| Address2: | |||||||||
| City: | DEXTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481309303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 FULLER RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 163WP0808X | 4704098180 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.