Provider Demographics
NPI:1467902734
Name:ROTH, CYNTHIA LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYNN
Last Name:ROTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KILLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05751-9476
Mailing Address - Country:US
Mailing Address - Phone:802-558-2572
Mailing Address - Fax:
Practice Address - Street 1:143 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:KILLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05751-9476
Practice Address - Country:US
Practice Address - Phone:802-558-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0003463225100000X
NH1572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist