Provider Demographics
NPI:1568157071
Name:ROTH, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 N CAMINO SECO APT 275
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2972
Mailing Address - Country:US
Mailing Address - Phone:724-953-5224
Mailing Address - Fax:
Practice Address - Street 1:5151 E BROADWAY BLVD STE 1500
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3787
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant