Basic Information
Provider Information | |||||||||
NPI: | 1679672570 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTH | ||||||||
FirstName: | JOANNE | ||||||||
MiddleName: | THERESE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4212 KENSINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482242769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138863811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 22708 HARPER AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT CLAIR SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 480801823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864452210 | ||||||||
FaxNumber: | 5804450700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 10/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801011882 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 106H00000X | 4101005871 | MI | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 1041C0700X | 6801011882 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.