Provider Demographics
NPI:1477790608
Name:ROTH, RICHARD HENRY (LCSW, MA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:HENRY
Last Name:ROTH
Suffix:
Gender:M
Credentials:LCSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6028 SOQUEL DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3115
Mailing Address - Country:US
Mailing Address - Phone:831-454-6487
Mailing Address - Fax:
Practice Address - Street 1:6028 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3115
Practice Address - Country:US
Practice Address - Phone:831-454-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical