Provider Demographics
NPI:1467964197
Name:ROTH, BAYLIE ZHEUTLIN (LSW)
Entity Type:Individual
Prefix:
First Name:BAYLIE
Middle Name:ZHEUTLIN
Last Name:ROTH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 W ELMDALE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2546
Mailing Address - Country:US
Mailing Address - Phone:630-750-2674
Mailing Address - Fax:
Practice Address - Street 1:1000 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1879
Practice Address - Country:US
Practice Address - Phone:773-281-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102774104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker