Provider Demographics
NPI:1124588686
Name:ROTH, MARIA (PTA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-3876
Mailing Address - Country:US
Mailing Address - Phone:215-601-3933
Mailing Address - Fax:
Practice Address - Street 1:8601 STENTON AVE
Practice Address - Street 2:
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-8312
Practice Address - Country:US
Practice Address - Phone:215-233-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004031225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant