Provider Demographics
NPI:1184036196
Name:ROTH, ROBIN GOLDBERG (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:GOLDBERG
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16820 MACANTHRA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4879
Mailing Address - Country:US
Mailing Address - Phone:704-807-5699
Mailing Address - Fax:704-631-4574
Practice Address - Street 1:129 N TRADD ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5239
Practice Address - Country:US
Practice Address - Phone:704-380-0799
Practice Address - Fax:704-278-0146
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-25
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10888OtherNORTH CAROLINA BOARD OF EXAMINERS - SEARCH SPEECH AND LANGUAGE PATHOLOGISTS