Provider Demographics
NPI:1225607740
Name:ROTH, SUSAN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11213 W 164TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-8530
Mailing Address - Country:US
Mailing Address - Phone:913-972-2397
Mailing Address - Fax:
Practice Address - Street 1:11213 W 164TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-8530
Practice Address - Country:US
Practice Address - Phone:913-972-2397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004281225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics