Provider Demographics
NPI:1346482270
Name:ROTH, TREVOR JUDE (LCSW, LCAS, CCS-I)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:JUDE
Last Name:ROTH
Suffix:
Gender:M
Credentials:LCSW, LCAS, CCS-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:LAKE JUNALUSKA
Mailing Address - State:NC
Mailing Address - Zip Code:28745-0712
Mailing Address - Country:US
Mailing Address - Phone:419-202-3350
Mailing Address - Fax:
Practice Address - Street 1:545 N LAKESHORE DR STE 102
Practice Address - Street 2:
Practice Address - City:LAKE JUNALUSKA
Practice Address - State:NC
Practice Address - Zip Code:28745-9742
Practice Address - Country:US
Practice Address - Phone:419-202-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0095621041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical