Provider Demographics
NPI:1437504883
Name:ROTH, EMILY ANN (MA)
Entity Type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:SUITE 2800
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000103TC2200X
IN20043113A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent