Provider Demographics
NPI:1326522210
Name:ROTH, LAWRENCE M (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16600 W SPRAGUE RD STE 245
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-6319
Mailing Address - Country:US
Mailing Address - Phone:440-523-0370
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE STE 363
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107
Practice Address - Country:US
Practice Address - Phone:440-523-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0600818104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
27-1334595OtherPRIVAT PRACTICE