Provider Demographics
NPI:1558518555
Name:ROTH, HEIDI ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 E TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4464
Mailing Address - Country:US
Mailing Address - Phone:812-606-9996
Mailing Address - Fax:
Practice Address - Street 1:1441 S FENBROOK LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4176
Practice Address - Country:US
Practice Address - Phone:812-606-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1926101YP2500X
IN39002155A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional