Provider Demographics
NPI:1093945552
Name:ROTH, DEBRA KAY (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:DEBRA
Middle Name:KAY
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 S WESTERN AVE
Mailing Address - Street 2:305
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-4520
Mailing Address - Country:US
Mailing Address - Phone:405-632-2949
Mailing Address - Fax:
Practice Address - Street 1:5350 S WESTERN AVE
Practice Address - Street 2:305
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-4520
Practice Address - Country:US
Practice Address - Phone:405-632-2949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-19
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005274A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist