Provider Demographics
NPI:1285632174
Name:ROTH, KARLSSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:KARLSSON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 E HIGHLAND AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4833
Mailing Address - Country:US
Mailing Address - Phone:602-863-0101
Mailing Address - Fax:602-863-9500
Practice Address - Street 1:2211 E HIGHLAND AVE STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4833
Practice Address - Country:US
Practice Address - Phone:602-863-0101
Practice Address - Fax:602-863-9500
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist