Provider Demographics
NPI:1134107816
Name:ROTH, ROBERTA (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
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 1:553 SPYGLASS DRIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-484-6986
Mailing Address - Fax:541-484-6986
Practice Address - Street 1:535 SPYGLASS DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2089
Practice Address - Country:US
Practice Address - Phone:541-484-6986
Practice Address - Fax:541-484-6986
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000174104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000TLCTPMedicare ID - Type Unspecified