Provider Demographics
NPI:1275553000
Name:ROUTH, TERESA (MA-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ROUTH
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 ARIANA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1879
Mailing Address - Country:US
Mailing Address - Phone:863-413-0802
Mailing Address - Fax:863-413-0812
Practice Address - Street 1:1335 ARIANA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1879
Practice Address - Country:US
Practice Address - Phone:863-413-0802
Practice Address - Fax:863-413-0812
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist