Provider Demographics
NPI:1477328011
Name:ROTH, EMERSON J (QMHS INTERN)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:J
Last Name:ROTH
Suffix:
Gender:F
Credentials:QMHS INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 JUNEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2605
Mailing Address - Country:US
Mailing Address - Phone:216-301-3661
Mailing Address - Fax:216-334-2882
Practice Address - Street 1:3135 EUCLID AVE STE 202
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2524
Practice Address - Country:US
Practice Address - Phone:216-391-2030
Practice Address - Fax:216-334-2882
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health