Provider Demographics
NPI:1093571457
Name:VON ROTH, SUSAN ALEXIS (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ALEXIS
Last Name:VON ROTH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:HUSSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 8484
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-8484
Mailing Address - Country:US
Mailing Address - Phone:207-619-3356
Mailing Address - Fax:207-300-6085
Practice Address - Street 1:30 DANFORTH ST STE 311
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4574
Practice Address - Country:US
Practice Address - Phone:207-619-3356
Practice Address - Fax:207-300-6085
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMF7402106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist