Provider Demographics
NPI:1417102781
Name:ROTH, JULIE ANN (SACIT)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:SACIT
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:STANISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9415 W FOREST HOME AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1680
Mailing Address - Country:US
Mailing Address - Phone:414-427-4884
Mailing Address - Fax:414-427-4889
Practice Address - Street 1:9415 W FOREST HOME AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1680
Practice Address - Country:US
Practice Address - Phone:414-427-4884
Practice Address - Fax:414-427-4889
Is Sole Proprietor?:No
Enumeration Date:2008-11-30
Last Update Date:2008-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15618-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)