Provider Demographics
NPI:1083636849
Name:ROTH, THERESA MAHER (MA OTR L CHT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAHER
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA OTR L CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19365 SW 65TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-692-5210
Mailing Address - Fax:503-692-8821
Practice Address - Street 1:19365 SW 65TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-692-5210
Practice Address - Fax:503-692-8821
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR360412225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5422910001Medicare NSC
ORR135015Medicare PIN