Provider Demographics
NPI:1518173640
Name:ROTH, SALLYANN (MSW)
Entity Type:Individual
Prefix:MS
First Name:SALLYANN
Middle Name:
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 1:137 BROOKS ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2243
Mailing Address - Country:US
Mailing Address - Phone:781-391-0620
Mailing Address - Fax:
Practice Address - Street 1:137 BROOKS ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-2243
Practice Address - Country:US
Practice Address - Phone:781-391-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist