Provider Demographics
NPI:1265670186
Name:ROTH, SUSAN (MS/CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS/CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WEST 86TH STREET
Mailing Address - Street 2:8C
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4062
Mailing Address - Country:US
Mailing Address - Phone:212-874-1240
Mailing Address - Fax:
Practice Address - Street 1:114 WEST 86TH STREET
Practice Address - Street 2:8C
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10024-4062
Practice Address - Country:US
Practice Address - Phone:212-874-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006579-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist