Provider Demographics
NPI:1427539121
Name:ROTH, NANCY E (LICSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:E
Last Name:ROTH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HALES HOLW
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-2417
Mailing Address - Country:US
Mailing Address - Phone:508-785-1971
Mailing Address - Fax:
Practice Address - Street 1:8 HALES HOLW
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:MA
Practice Address - Zip Code:02030-2417
Practice Address - Country:US
Practice Address - Phone:508-785-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA00-1020296104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00-1020296OtherDIVISION OF PROFESSIONAL LICENSURE