Provider Demographics
NPI:1174663678
Name:ROTH, KRISTIN LYNN (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:ROTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 SE GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-2702
Mailing Address - Country:US
Mailing Address - Phone:330-207-2037
Mailing Address - Fax:
Practice Address - Street 1:332 SE GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2702
Practice Address - Country:US
Practice Address - Phone:330-207-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009186235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000217945OtherANTHEM
OH8674500Medicaid