Provider Demographics
NPI:1326533639
Name:ROOTH, MELISSA B (LCPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:ROOTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:773-294-0176
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 510
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4581
Practice Address - Country:US
Practice Address - Phone:773-294-0176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18101YP2500X
180101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional