Provider Demographics
NPI:1255847141
Name:ROUTH, MARIAH JEAN
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:JEAN
Last Name:ROUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 LAKEWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-8403
Mailing Address - Country:US
Mailing Address - Phone:785-844-3055
Mailing Address - Fax:
Practice Address - Street 1:6330 NW KELLY DR STE A
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-4027
Practice Address - Country:US
Practice Address - Phone:816-469-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KS1-20-45376103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician