Provider Demographics
NPI:1083862072
Name:ROTH, CHARLENE JEAN (LMFT)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:JEAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0292
Mailing Address - Country:US
Mailing Address - Phone:260-463-6915
Mailing Address - Fax:260-499-4158
Practice Address - Street 1:5460 N 450 W
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-8504
Practice Address - Country:US
Practice Address - Phone:260-463-6915
Practice Address - Fax:260-499-4158
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001635A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist