Provider Demographics
NPI:1518100999
Name:ROTH, ELLEN A (MSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAGUIRE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-3114
Mailing Address - Country:US
Mailing Address - Phone:781-860-1730
Mailing Address - Fax:781-860-1766
Practice Address - Street 1:1 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-3114
Practice Address - Country:US
Practice Address - Phone:781-860-1730
Practice Address - Fax:781-860-1766
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10156971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical