Provider Demographics
NPI:1336501857
Name:ROTH, LISA SHARON (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SHARON
Last Name:ROTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 LAUREL ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1951
Mailing Address - Country:US
Mailing Address - Phone:415-346-1234
Mailing Address - Fax:
Practice Address - Street 1:399 LAUREL ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1951
Practice Address - Country:US
Practice Address - Phone:415-346-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical