Provider Demographics
NPI:1457641110
Name:ROTH, MICHAEL PAUL (MA, BCBA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAUL
Last Name:ROTH
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 BIRCHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-9385
Mailing Address - Country:US
Mailing Address - Phone:717-433-2598
Mailing Address - Fax:
Practice Address - Street 1:3834 BIRCHWOOD CIR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9385
Practice Address - Country:US
Practice Address - Phone:717-433-2598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-10-7586103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst