Provider Demographics
NPI:1578807228
Name:ROTH, THERESA MARY (RD)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARY
Last Name:ROTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21386 FERNBROOK CT
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-4032
Mailing Address - Country:US
Mailing Address - Phone:703-851-8932
Mailing Address - Fax:
Practice Address - Street 1:21351 GENTRY DR
Practice Address - Street 2:SUITE 125
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8510
Practice Address - Country:US
Practice Address - Phone:703-851-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA847358133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered