Basic Information
| Provider Information | |||||||||
| NPI: | 1417102781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SACIT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANISH | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9415 W FOREST HOME AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | HALES CORNERS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531301680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | 4144274889 | ||||||||
| Practice Location | |||||||||
| Address1: | 9415 W FOREST HOME AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | HALES CORNERS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531301680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | 4144274889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2008 | ||||||||
| LastUpdateDate: | 11/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15618-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.