Provider Demographics
NPI:1326105719
Name:ROTH, KRISTI (OT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 EFTY CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4509
Mailing Address - Country:US
Mailing Address - Phone:703-583-2431
Mailing Address - Fax:
Practice Address - Street 1:2950 DALE BLVD
Practice Address - Street 2:
Practice Address - City:DALE CITY
Practice Address - State:VA
Practice Address - Zip Code:22193-1120
Practice Address - Country:US
Practice Address - Phone:703-583-1222
Practice Address - Fax:703-583-1499
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000443225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008733A53Medicare ID - Type Unspecified