Provider Demographics
NPI:1558585158
Name:DANIEL-ROTH, DIANA (BLS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DANIEL-ROTH
Suffix:
Gender:F
Credentials:BLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 60TH AVENUE TER W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4422
Mailing Address - Country:US
Mailing Address - Phone:941-753-3519
Mailing Address - Fax:
Practice Address - Street 1:2714 60TH AVENUE TER W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-4422
Practice Address - Country:US
Practice Address - Phone:941-753-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist