Provider Demographics
NPI:1467780841
Name:ROTH, GARY DEAN (LPC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DEAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 SHRESTHA DR STE D
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2171
Mailing Address - Country:US
Mailing Address - Phone:989-220-3060
Mailing Address - Fax:
Practice Address - Street 1:4151 SHRESTHA DR
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2171
Practice Address - Country:US
Practice Address - Phone:989-203-0602
Practice Address - Fax:989-684-4331
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007486101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509139660OtherBCBS
MI0G96288Medicare UPIN