Provider Demographics
NPI:1124015771
Name:ROTH, LEAH ELIZABETH (MSW)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:ELIZABETH
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:LEAH
Other - Middle Name:E
Other - Last Name:EXLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2333 KNOB CREEK RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2007
Mailing Address - Country:US
Mailing Address - Phone:423-952-0500
Mailing Address - Fax:423-952-0005
Practice Address - Street 1:2333 KNOB CREEK RD
Practice Address - Street 2:SUITE 11
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2007
Practice Address - Country:US
Practice Address - Phone:423-952-0500
Practice Address - Fax:423-952-0005
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4085357OtherBLUECROSS BLUESHIELD
TNTN0103OtherJOHN DEERE
TN3927292Medicaid
TN3927292Medicaid