Basic Information
| Provider Information | |||||||||
| NPI: | 1154757045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BEECH ST BLDG 10 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617611493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094635800 | ||||||||
| FaxNumber: | 8339142704 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209010719 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 277000959 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 783333 | 01 | WI | PROVIDER STATE LICENSE | OTHER | 35957000 | 05 | WI | MEDICAID |