Provider Demographics
NPI:1104013564
Name:ROTHERA, CAROL K
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:K
Last Name:ROTHERA
Suffix:
Gender:F
Credentials:
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 158
Mailing Address - Street 2:1099 MARYLAND CIRCLE
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-0158
Mailing Address - Country:US
Mailing Address - Phone:484-237-8477
Mailing Address - Fax:
Practice Address - Street 1:491 JOHN YOUNG WAY STE 300
Practice Address - Street 2:LIFE COUNSELING SERVICES
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2567
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC00-4271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional