Provider Demographics
NPI:1538304324
Name:ROTH, AMY MARIE (MS, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:WERNISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 S SYCAMORE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-3711
Mailing Address - Country:US
Mailing Address - Phone:605-838-8545
Mailing Address - Fax:605-271-4155
Practice Address - Street 1:1500 S SYCAMORE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-3711
Practice Address - Country:US
Practice Address - Phone:605-838-8545
Practice Address - Fax:605-271-4155
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7202101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor