Provider Demographics
NPI:1265023642
Name:ROTH, SU
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:
Last Name:ROTH
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 1:8633 CASTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2759
Mailing Address - Country:US
Mailing Address - Phone:317-775-4994
Mailing Address - Fax:
Practice Address - Street 1:8633 CASTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2759
Practice Address - Country:US
Practice Address - Phone:317-775-4994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker