Provider Demographics
NPI:1568659126
Name:ROTH, REBECCA (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-0133
Mailing Address - Country:US
Mailing Address - Phone:231-340-9113
Mailing Address - Fax:
Practice Address - Street 1:560 W MITCHELL ST STE 208
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2278
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:313-576-1091
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013498103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical