Provider Demographics
NPI:1356648489
Name:ROTH, LESLIE KARP (EDD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:KARP
Last Name:ROTH
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 JONATHANS BAY CIR
Mailing Address - Street 2:402
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7229
Mailing Address - Country:US
Mailing Address - Phone:239-433-4577
Mailing Address - Fax:
Practice Address - Street 1:681 GOODLETTE RD N
Practice Address - Street 2:STE 150
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5458
Practice Address - Country:US
Practice Address - Phone:239-434-9512
Practice Address - Fax:239-643-5908
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist