Provider Demographics
NPI:1497885883
Name:ROTH, STACEY ROBIN (LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ROBIN
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 AVENUE 64
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2711
Mailing Address - Country:US
Mailing Address - Phone:323-254-2274
Mailing Address - Fax:
Practice Address - Street 1:940 AVENUE 64
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2711
Practice Address - Country:US
Practice Address - Phone:323-254-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS190061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical